What about patient reform?

I.

Health care reform continues to remain a rather hot topic for those least-informed on the issue (read: Americans). This singular issue has effectively defined the Obama presidency and led to the development of his brain-child known as ObamaCare. While there are a fair number of good things that came from this (expanding coverage regardless of how shitty said coverage may be), there has also been a number of terrible things to come from this (VBP, bundle payments, Burwell, etc). The goal of this reform has explicitly been to decrease the cost of healthcare; everyone seems to ignore the asterisk at the end denoting the phrase “at healthcare’s expense”. I have already briefly touched on the reforms meant to penalize hospitals for failing to meet arbitrary quality improvement standards or patient satisfaction quotas. I have also touched on the change in payment plans, specifically bundle payments. All of these programs have one goal which is to gradually push more of the tab for treatment onto the hospitals, similar to pushing the cost back on a widget manufacturer for delivering a boat load of broken widgets. Nobody wants to pay for broken widgets, so why should the government? The problem with this though is that A) hospitals are not factories B) all the widgets were made somewhere else and C) a significant portion of those widgets are apathetically trying to break themselves. To bring it back to the widget factory, this is the equivalent of fining a factory for not fixing broken widgets they received involuntarily from some Indonesian sweat shop which were already programmed to self-destruct. This is our current health care system.

Patient compliance is one element of healthcare that seems to have been purposefully avoided. I say purposefully because throughout the medical community it is the biggest complaint among all physicians but somehow has rarely made it into the national conversation. For anyone that is not familiar with this term, patient compliance has to do with the patient actually listening and doing what we ask of them in order to better their own lives through treatment of their medical conditions. One may expect that if there is a person seeking out a professional opinion that could prolong their life that the said person would make it a point to… you know… follow that advice. You may expect that everyone, save for those overtly suicidal, would make it a point to actively preserve their own lives. You would be wrong. Depressingly wrong.

Let me provide you with some examples.

Exhibit A: Jon D

Jon is a young gentleman in his 20s with type 1 diabetes that decided at an early age he was going to have approximately zero shits to give. Ever. He is well-known throughout the hospital because he is admitted every 1-2 weeks, for the last 5 years, for diabetic ketoacidosis (DKA) as he refuses to use insulin. Frequently, he is admitted to the ICU due to the severity of his DKA. Thousands of dollars are spent each hospitalization to provide him with IV insulin, fluids, electrolyte replacement, endocrine consultation, and nursing care. We get his glucose under control and provide him a stable insulin regimen. But after a few days, he comes right back to the hospital to repeat the entire episode again. He is what we in the biz call a “non-compliant patient”.

Exhibit B: Jamie Q

Jamie is a good, wholesome, middle-aged, Trump-voting, salt of the earth with type 2 diabetes. She has had diabetes for quite some time now, going on 30 years. She goes to the doctor but seems to not pay any attention. She gets her pills filled and remembers to take them less than half the time. Eventually, she requires insulin which she also avoids taking because needles suck and counting is complicated. After years of devout ignorance, she gradually loses a significant portion of her sight, has two heart attacks, a mild stroke, and one and a half feet removed from gangrene resulting from multiple diabetic foot ulcers after not wearing shoes. She is a frequent flyer in the hospital for various reasons and has been a patron of multiple different nursing facilities. She is a “non-compliant patient”. But hundreds of thousands of dollars later, Jamie does end up becoming compliant after being enrolled into a long-term care facility and having all of her medications administered to her after she becomes completely disabled from an additional stroke involving half her brain.

Exhibit C: Don K

Don is well-known to the ED staff. Don comes in multiple times a month for a variety of substance-related complications. Don loves his alcohol, he loves his cocaine, and he is starting to love his heroin. Don would be homeless if it was not for section 8 housing and a whole slew of other safety-net programs, Medicaid included. Don is not always admitted, sometimes he sobers up enough to leave belligerently from the ED, but he does find himself spending a few nights at the hospital several times a month with at least one of his problems being alcohol withdrawal. During his admissions, Don tries to refuse most care, complains endlessly about the quality of his meals, and makes it a point to leave the floor to go smoke several times a day. He is always discharged in “stable” condition. He is a “non-compliant patient”.

I could repeat the alphabet several times over with various examples of the “non-complaint” patient but I think the point is received: thousands, if not millions, of people want nothing to do with their own well-being.

“But why do you care? Isn’t that on them?”

I don’t care. At least, I don’t care that they make dumb decisions. Everyone makes dumb decisions. The human race is defined by dumb decisions. The problem is not the dumb decisions and lack of foresight; the problem is that I get penalized for their dumb decisions and lack of foresight. Their dumb decisions have greater consequences than just screwing themselves over. That’s why I care.

II.

Let us look back at value-based purchasing. I have already spent a fair amount of time discussing the insanity which is this terrible program. But in order to drive the point home further, we need to look at this push for “quality” through the filter of patient compliance. Let us start with re-admission rates.

One of the objectives that have been used as a means to determine “quality” has been to try and lower re-admission rates to the hospital. This objective has been established through a whole series of poor and inaccurate assumptions. These assumptions include but are not limited to: assuming that every patient makes every effort to improve their own health, assuming that physicians and hospitals have the power to stamp out effects of chronic and progressive diseases, assuming patients (baby boomers) are not consistently getting older and acquiring more chronic and incurable disease, assuming that patients are listening intently to everything we say and simply are not informed enough, assuming that physicians make it a point to not spend any time with patients purely out of a desire to get back to swimming in their money pools, and assuming that physicians are Jedi Masters able to wave their hands and fundamentally change patients for the better. Through these, and likely other, assumptions, CMS/HHS/Burwell have made it a point to punish hospitals if certain patients were to be re-admitted to any hospital within 30, and sometimes up to 90, days. These punishments are often financial and include limiting any further payments to the hospital for those encounters as they clearly should have been preventable with the fault laying squarely on the shoulders of the health care professionals. Hospitals and physician groups have invested a lot of money to try and bring this number down. But has it been effective?

Well, if you take Burwell for her word and refuse to look at her sources cited, the answer is yes. The number has objectively gone down. But what happens when you look at her sources? Well, the results seem less impressive. Prior to Obamacare, the re-admission rate was hovering around 19%. For the years after the Reckoning, the percent has hovered around 17-18%. WE DID IT! YES, WE CAN! This number seems to have been fairly stagnant since. But despite this miraculous change in re-admission rates (the view in which I assume Burwell takes), every hospital that I have any interaction with seems to be at near max capacity save for the rural hospitals that make it a point to transfer all their patients to larger hospitals.

Again, hospitals have invested millions of dollars in attempts to decrease readmission rates. We go through great lengths to provide patients with free medications, education for appropriate medication use, quick follow up appointments, nursing home placements (if needed), durable medical equipment at home, home health care, and even assist with applications for Medicaid. But despite all of this, many of these patients keep coming back. What are we supposed to do?

III.

Well, the answer seems rather simple, assuming you are not a physician. According to a number of paper monkeys (Ph.D’s), the solution to the problem involves simply talking to the patient. I can safely assume they have never spoken to a patient.

Kaplan and Co (NEJM 11/2016) dedicate an entire article to poor assumptions and made up calculations. They use two different chronic diseases, CKD and diabetes, to demonstrate how “talking” can add value. In the setting of worsening CKD (chronic kidney disease) and impending need for dialysis, our Ivory Tower colleagues cite the use of temporary tunneled dialysis catheters for the initiation of dialysis as a failure of nephrologists to adequately discuss fistula placement with patients due to their high patient volume (more on this later). They claim that $200 in patient discussion (a completely made up number) can save $20,000 over six months in catheter insertion and potential complications. In regard to diabetes management, it is suggested that the only reason why patients are non-compliant with their insulin therapy is that the physicians and other staff did not spend enough time explaining the importance of the medication or appropriately address the patient’s concerns. Never mind the fact that most of these patients were non-compliant with pills for several years before insulin was ever on the table.  In addition, it should be noted that a large number of uncontrolled diabetics often progress to end-stage renal disease. So, that same patient population that was non-compliant with pills, that you are supposed to convince to use their insulin, will end up establishing with a nephrologist and somehow be expected to be convinced to drop their impenetrable ignorance barrier and replace it with proactive insight.

A girl can dream.

In this same article, Kaplan and Friends continues down the road of unsubstantiated claims without even an attempt at citing relevant sources. “Several studies” apparently show that the more time you spend with patients the more compliant they are. It is interesting that despite there being “several”, they cannot be bothered to simply cite one. He eventually does go on to cite an article showing increased conversations with family, patients, and treatment teams of “high risk geriatric” patients had positive effects such as decreased cost and higher quality of life. However, if you take the ten seconds to look at his sources, the article he cites is from a study involving metastatic lung cancer patients. Although technically they can be “high risk geriatric” patients, this is extremely misleading to the point of blatant deception. Kaplan suggests increasing uses of phone calls, electronic communications, and greater office staff involvement of reminding and encouraging with the estimate costs of these changes in the “tens to hundreds” of dollars. Again, there is still no word on exactly how these magical calculations were made, but you should just accept it as fact. Lastly, we are presented with “real life” examples of how certain health care organizations are getting it right. Kaplan makes it a point to show how the time and money spent by Kaiser Permanente for “high need” Medicare beneficiaries was able to decrease their hospital costs and how weekly meetings of physicians in the M.D Anderson Cancer Center to discuss new patients has supposedly led to better patient care. What he fails to mention, but is obvious to most exposed to this article, is that these two organizations are behemoths with deep pockets. Not to mention, Kaiser is an organization with a huge network for which they can easily adjust costs and M.D Anderson is a cancer hospital that only has to meet and discuss things relevant to cancer. Good luck getting a group of specialists to sit down for a lengthy, non-reimbursable discussion about every diabetic with hypertension, morbid obesity, and renal dysfunction.

IV.

Let us ignore reality for a moment. Let us hold hands with our Ph.D friends above and jump into the world of make-believe. Let us assume that all a patient needs are more “Go Get’Em’s”, back pats, and words of encouragement before they see the light and dutifully take their medications and listen. Where is all this time going to come from?

There seems to be some weird misconception that by doing away with fee-for-service that you are somehow lightening the physician load and allowing them to spend more “quality time” with patients. As I have already tried to make clear, the new system of bundled payments does nothing of the sort. In this new age, where you will be paid a set amount with adjustments (read: deductions) made for “quality”, you are incentivized (read: required) to see a larger number of patients in a day; the nephrologist from before is not being rewarded for spending more quality time. As some may point out, there are ways in which to bill for time spent conversing with patients, however these codes are infrequently used and do not sufficiently reimburse for the time spent. Furthermore, exiting the exam room does not end the time spent with the patient. In our modern era of instant gratification, a barrage of electronic messages or phone calls come in daily from multiple patients a day. Some of these are simple medication refills or FYIs, but a large number of them tend to be things we need to spend at least a little time on. And again, sometimes these communications are billable (by some insurance companies) but the catch is that you often do not have time to bill for them as you are too busy dealing with everything else in a day. Or worse, you are too intimidated to bill for these encounters as you may bill incorrectly and be fined for over-billing. It’s interesting how no one really cares too much if you under-bill though, except the office manager, so you are screwed either way.

“So, are you just in it for the money?”

No, but I would like to be reimbursed for my time. Wouldn’t you? Or is the act of working overtime a reward unto itself?

V.

“Ok, so, how do we fix it? You spent a lot of time complaining but do you have any solutions?”

I do. But you won’t like them.

As physicians, the first thing we need to do is stop being cowards. I know this is hard, given our propensity for cowardice, but we need to speak truth to stupidity. Those patient examples given above, the reality of the situation, needs to come to the forefront of the conversation. We need to quit sweeping it under the rug and start to hold people accountable for their actions. We cannot control the actions of others, no matter how persuasive we are expected to be, and we cannot be expected to serve as parents for an entire country of overgrown children. They should learn to wipe their own ass or get used to smelling like shit.

Second, we need to shun and banish those that attempt to guilt or shame us in order to distract us from the truth. Let us go back to Kaplan. The following quote is a perfect example of what I mean.

“Clinicians who are reimbursed under new value-based payment plans should seize the initiative to determine how much of their valuable time should be spent in the various types of productive conversations, especially as they become more accountable for their results”

Pay close attention to the wording and its insidious meaning. At first glance, this could be seen as inspirational; it’s a call to arms for improving health care. But upon further inspection, you can see that this statement is based on several faulty and dangerous assumptions. For starters, the assumption that the new value-based payment system creates a nurturing environment for these time initiatives is clearly wrong; the very use of the word “initiative” implies a degree of freedom and self-direction which is entirely absent. These “initiatives” are mandates which serve as nothing more than unobtainable objectives that are made unobtainable by rules being created by those enforcing the mandates. It is impossible to spend more time with patients when you are forced to see an increasing number of patients in a day for dwindling returns. But more importantly, even if you find a way to take that extra time, there is no guarantee that it will pay off. This game is set up to maximize failure; the house always wins. They win at our expense.

But why do we allow this to go on? I am sure I am not the only one that has noticed what is going on. I can’t be. That would be insane.

We allow it to happen because we have internalized a deep sense of guilt evident by the last part of the quote which is utilized to invoke that particular sentiment:

“as [physicians] become more accountable for their results”

We are accountable. We are accountable for every action a patient takes, or doesn’t take, and we are accountable for the result. We are accountable for not explaining things appropriately, regardless of how much time we take. We are accountable for their bad outcomes. If only we could find a way to get through to them, if only we could take more time out of our day to communicate more effectively, if only…. This is the line of thought that we are being fed and expected to internalize. It is not their problem, it is ours. This is the chain around your neck, attached to an anchor, threatening to drown you. Your options are to break the chains or hold your breath. Which do you choose?

V.

“So, we need to grow a pair and stop feeling guilty? That’s it?”

It’s a start. But remember, the system does not like change, especially change which could be bad for the system. Even more importantly, the system is not being run by physicians but by patients. Think about it. How much gray hair resides in your state congress? In the federal congress? Everyone with gray hair is, or has been, a patient at some point. Do you really believe that patients are going to make changes to health care that could negatively impact them by holding them accountable for their actions? Do you think career politicians are going to risk upsetting a sizable chunk of their constituents by advocating for policies that may make them work harder or incur some financial penalty? The answer is obvious: sacrifice the minority to appease the masses. The problem with this simple calculation though is that it ignores the amount of power that the minority possesses. Thankfully, the system has done an excellent job in ensuring that same minority remains ignorant of its own power.

And this is why we will not have to worry about patient reform.

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