Tag: health care

Us-Versus-Them

There is a weird dynamic that occurs in nearly every hospital setting around the country. It’s a hostile dynamic that seems to be older than time and almost hard-wired into everyone that partakes in this seemingly fruitless endeavor known as health care. It’s an Us-versus-Them dynamic which oddly enough seems to pit physicians against nurses.

“That doesn’t make sense. Aren’t they supposed to work together?”

Indeed.

I.

The tension is immediately palpable upon your first day of third year clerkships as a medical student. If you think back hard enough, maybe you can remember the first time you walked unto the floors, asked a nurse a question, and were met with either indifference or resentment. The interaction may have surprised you. It was just a routine question, wasn’t it? Maybe the nurse was having a bad day? Regardless, you continue to solider through in your ignorance while nervously seeing patients and hoping to not make an ass of yourself in front of the attending. However, inevitably, you must approach the nurses again to ask about/for something. You proceed in your seemingly mundane and innocent task but ultimately are still left with the impression that you serve no purpose but to be a pain in their collective asses. Occasionally, you will have interactions with the nurses that are pleasant. Just as there are a handful of surgery residents who do not harbor bitter resentment and rage towards every living thing, there are also nurses who make it a point to interact with the “lessers” as if they were human beings.  These interactions are few and far between though. By the end of your fourth year, you have a clear understanding of how things work; you know which train tracks not to cross. And this is just in time for you to begin your residency where you get to see things from a whole new perspective.

Intern year is where you begin to clearly see the divide. At this point in your medical career, you effectively know a lot about nothing. And the nurses know this. At this stage, you are going to screw up, a lot. Like, a lot a lot. You are going to be too conservative in some matters and then too liberal in others. You are going to hedge when talking with family members and give too much hope when there is none to be had. You are going to contradict the nurse, even if you do not intend too, and create tension. The nurses expect this. They have been through it all before. Some nurses may even be able to do your job better than you. But still, and despite this, they are obligated to follow whatever you haphazardly put into the chart; it is a life of Groundhog’s Day just with different actors. They may call you about it, clearly annoyed, and demand you fix it. Or other, more subversive, nurses will follow the order to the T. At this point, animosity often arises and becomes rather obvious even to the dimmest of bulbs. And how do the nurses best convey their frustrations? It’s not by direct confrontation; that is a big No-No as many nurses have often been burned in the past for these types of actions. Their weapon of choice: passive-aggression.

You know it when you see it, the nurses that have taken up their passive-aggressive arms. You will receive a thousand pages for stool softeners, electrolyte replacements, diet orders, Tylenol, anti-emetics, and narcotics. You will never be called doctor; in their eyes, you are a baby doctor that barely knows how to crawl and is always covered in shit. They will interrupt you on rounds to give “updates” that contradict the information you obtained, they will question every decision you make, and they often will “go up the chain” when they disagree with you until they get an answer they like. And they will do this all in the name of “patient advocacy” because it is the ultimate trump card; it is the equivalent of invoking God’s Will as the reason for your actions. And as this goes on, as the pages piles up, and as the years tick by, things may get a little better. Eventually, you become the senior resident and no longer have to field the majority of pages, you are not presenting during rounds, and you are officially higher up on that “chain” where you can have a final say. But the memory of the past still haunts you, it still leaves a bitter taste in your mouth. Again, there were nurses along the way that were decent, amiable, and easy to interact with, but their light has been extinguished by the mounds of shit which was otherwise known as your day-to-day. And as you near the end of your indentured servitude, filled with the ugly memories of your war days, you hold on to that world-view of “Us-versus-Them” as you transition into becoming the illustrious Attending.

As an attending, you are now addressed as “Doctor”. Much of the overt rudeness you may have experienced as a resident appears to have quickly disappeared. You are at least given the impression of having more respect. And right or wrong, sometimes you may even feel like you earned it, so now you make your move. When you receive a page or call from nursing regarding a less than pressing matter, you lash out, belittle, or demand further information and a call back before hanging up. You demand to be called “Doctor”. You have little or no regard for how the timing or placement of your orders may inconvenience the nursing staff and may even erupt in a fit of indignation when something was not done perfectly the first time. And the best part? Despite occasionally acting like an impetuous child, no one will call you on it. You are the boss! Absolute power corrupts absolutely.

But despite the fact that the nurses may not outright call you a flaming dick bag to your face, they sure as hell are seething about it when you are nowhere to be found. They hate how you respond to requests for orders or information, despite the fact that it is their job to make such requests. They brace for impact when they see your name on the chart and have likely bitched to various supervisors which ultimately have no power to make changes. They will likely still use their tried and true method of passive aggression on you, which will be irritating, but you are still in control. They know that. And they hate that. And that hatred, since it can’t be paid back, is paid forward. And the cycle continues.

II.

It may appear that I have put all of this on the nurses, that I have accused them of throwing the first stone. Let me assure you, I have not. I do not know if anyone will ever know who drew first blood in this seemingly endless war as this information is likely lost in time. If I had to wager a guess though, I would bet on the physicians as cause of the initial insult. Unlike the role of physician, residents have only been a fairly recent phenomenon. Back in “the day”, many physicians just did apprenticeships with anyone that would have them, regardless of any true credentials. There were no large, urban hospitals, health insurance reviews, M&M conferences, practice standards, malpractice, or even many legitimate treatments. Hell, nursing was not even a profession until the mid-1800s and seemingly in response to most nurses at the time being rowdy drunks and assholes. Seriously.  So taking this into account, I imagine that physicians may have had to be raging ass hats towards a certain percentage of the nursing staff to distract them from their gutter whiskey long enough to perform a task that could have potentially been life-saving. Or unwittingly tortuous. Back then, it was kind of hard to tell which it was. Assuming this to be correct, or close enough, this culture has seemingly persisted throughout the ages despite the unfortunate lack of alcohol and boxing matches currently allowed in modern hospitals. But now, the physicians are not just magically appearing “fully trained” and the nurses find themselves in a position of relative power during the physician’s formative years. Let the hazing begin!

But the origin of blame is not the point. Assigning blame in this eternal conflict only distracts from the more salient issue of why this system is even in place. What good comes from the perpetuation of the “Us-versus-Them” culture? Is it good for the patients? Is it good for the hospital? Answer: It’s good for the system.

III.

It’s all about control. As I have already elaborated on, you need to distract and demoralize those you intend to control in order to make them accept your command without question. This is especially true when the servants possess the power; you need to make sure they never use it. In our current system, the nurse resents the physician for built-in subservience and the physician resents the nurse because they seemingly make their job, and by extension, life more difficult. Both camps seem to be too caught up in the conveniently constructed struggle to notice that they have a mutual adversary: the patient.

It is no secret among the health care community that the vast majority of patients that are encountered in the hospital setting are nothing more than morbidly obese, cognitively impaired, adult-themed children that are hyper-focused on the irrelevant. These patients seek nothing more than narcotics and food and invariably complaint about both the speed in which they are acquired and the pleasure that is derived. I’ve had multiple patients come in unable to breath and demand a hamburger, mashed potatoes, and soda; I’ve offered them hospice with only a minimal amount of facetiousness. Sadly, they never take me up on it. Instead, they somehow find a way to survive their hospitalization with only a minimal number of aspiration events and are eventually released back into the wild to inevitably be re-admitted again.

These “patients” serve as the impetus for the eternal conflict. They are the initial reaction that sets off a cascade of events resulting in frustration. These are the patients that the nurse is constantly calling about narcotic orders, diet orders, non-compliance with treatment, need for frequent updates, and threats of leaving AMA. These are the patients that the doctor hears about ad-nauseam that lead to a full rage meter and broken pagers. It is these patients that serve as the kindling which ignites the fire that consumes any chance of decent working relationships. They are the central cog in the system’s design however their ignorance is so great that I doubt they even understand the role in which they play; the role of the unilateral rage generator.

No matter how horrible and ridiculous they may be, patients are untouchable, especially in this era of “Health care as Business” where they will soon be referred to solely as “customers”. Save for some likely isolated incidents, the nurses are not yelling back at the patients, they are not (rightfully) telling them to go fuck all the way off, and they are not refusing ridiculous requests. Similarly, most physicians will allow these patients to run right over them in an attempt to save time by avoiding conflict in the hopes of still obtaining that coveted “9 out of 10”. Sure, some of the really crazy ones get their Haldol levels replenished, but this is not the norm.

So, what happens with this rage? Well, as alluded to above, it bounces back and forth between the physician and nurses until all they can see is their respective disdain for each other. And this does not just happen once a day, this happens several times a day. The battle royale known as “physician vs nurse” is continually powered all to the delight of the system; we are nothing but dancing puppets.

But the system is not happy with just physicians and nurses pitted against each other. The system has set up redundant circuits of in-fighting. Have you ever seen the ICU and PCU nurses get along? Have you ever seen the PCU and general floor nurses get along? How about different physician subspecialties? One could answer “yes” to any of the above, but they could not truthfully claim that it is the norm.

IV.

Think about what could happen if physicians and nurses suddenly woke up one day and began to work together. What if we started to direct our energies away from tearing each other apart and instead focused those energies on demanding patient reform? What if those energies were directed towards the bureaucrats and administrators that set the arbitrary rules which seem to govern our lives? What if those frustrations and anger were directed towards the national health care debate in an attempt to bring to light the true issues which make health care expensive? What if instead of focusing on our own bickering when faced with irrational regulations, we simply provided a collective reply of “I prefer not to”?

But unfortunately, there are dilaudid orders to place and nurses to chew out. So I guess we’ll never know.

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.

You Get What You Pay For

Healthcare is expensive. This is a fact. To get into the details for why it is expensive is a topic for another time. But the big push over the last few years has been to decrease the cost of healthcare. More to the point, the push to decrease cost of healthcare has been to simply pay less for healthcare by the government through Medicare and Medicaid. Ever since President Obama passed his magical ObamaCare act, the healthcare system has been in a constant state of flux. CMS/HHS (center for Medicare) has been churning out new rules and initiatives at break-neck speeds all in an attempt to leave most hospitals and healthcare systems in a state of fear and bewilderment; they are the Neagan to our Rick. By this point, most of the larger hospitals and healthcare systems have fallen in line and “volunteered” to start choking down at least one of the alternative plans for reimbursement. But what effect will this have? What do we have to look forward to?

I’m glad you asked.

I.

A quick perusal through the CMS website will grant you information on the BPCI, which is the bundled payment plans for hospitals and post-acute care facilities. There are 4 different models with models 2-4 being the primary options. For reasons that become rather obvious, model 2 is the overwhelming favorite in the same way that getting smacked in the face is preferable to getting kicked in the balls. Briefly, model 2 (BPCI-2) retrospectively pays a bundle payment based off an episode of care to hospitals that participate in the program while still paying the fee for service rates to the physicians. In other words, if you have Medicare and come in with a pneumonia then Medicare will continue to “pay” like fee for service while you are in the hospital but will then compare that cost to their pre-determined bundle payment after you are discharged and come to a reconciled final amount to pay the hospital after the fact. This also includes post-acute care costs 30, 60, or 90 days out. Thankfully, this does not include physician costs. This beats model 4 (BPCI-4) where Medicare prospectively (as soon as you enter the door) pays a bundled amount without negotiation which is also to include your post-acute care costs as well. This includes physician costs. At this time, only 10 programs are dumb enough to continue down the model 4 road.

Now, for all these hospitals included in the above plans, they get to pick from a list of 48 distinctive diagnoses to be used as benchmarks for comparison to other hospitals as well as for reimbursement purposes. Not surprisingly, most picked major joint replacements with far less picking such exciting things like heart failure and COPD. Being able to pick the metric that is to be used as a tool for grading and scrutinizing oneself must be a nice perk. I hope the hospitals enjoy it while it lasts. I also hope they also enjoy believing that this is all “voluntary”.

But I digress. Someone must want to know how hospitals are doing when it comes to decreasing cost and improving quality through metrics of their own choosing, right? CMS sure as hell does! They hired a company to put together a report published in August 2016 based off information through 2014 to look at how things were going. Here are some highlights:

  • Orthopaedic surgery costs on average went down $864, they sent people to less SNFs [skilled nursing facilities] (64% to 57%), and those that went to SNFs spent 1.3 days less. The down side? Medicare paid, on average, $2137 less per episode from baseline through the intervention period. Ouch. Keep in mind, 75% of hospitals participated in this metric.
  • Cardiovascular surgery saw relatively stable reimbursement through the intervention period (Great!) as long as they did not go to a SNF (SHIT!). If the patient had to go to a SNF, or any other institution post-discharge, hospitals were on average shorted $4149. Now, their rates for SNFs decreased (55% to 44%), but that is still a large number. Furthermore, their ED visit rate increased as well. Can you imagine what this looks like yet?
  • Lastly, spinal surgery seems to be the only success story (or failure, depending on your prospective). Their reimbursement INCREASED $3477 with overall no major changes. Guess what specialty is next on the chopping block?

In short: it appears cost is going down but reimbursement may be going down at a faster rate.

“But aren’t there incentives like value-based purchasing which are supposed to reward high-performing hospitals?”

Excellent question! Let us look at this value-based purchasing program initiated by CMS. This is a program with the goal of rewarding “quality” of care over “quantity” of care. Sounds like a great idea until you realize that both those words effectively mean nothing and are little more than trite, banal aspirations set forth by the demon princess, Sylvia Burwell, herself.

The Value-Based Purchasing program is a program that came into effect in 2013 and seems to gradually change every year in some shape or form. It allows CMS to base payments off “Set measures and dimensions grouped into specific quality domains”. At this time, two percent of Medicare reimbursements are being tied to this program and the score which determines whether or not you see any of that money again is based on some revolving and arbitrary criteria. Below is an overview of how each is weighted:

VBP Image

  • Outcomes = Safety and patient experience = patient and care-giver experience.

Take a second to really read that chart.  I want you to try and imagine what this program is really trying to reward. From 2016 there is a 40% weighing towards outcome/safety which drops off to 25% by 2018. By 2018, your safety/outcomes are as important as your “experience” in the hospital. To put it another way, it is equally important that you enjoy your hospital dinner as it is that you not get a surgical site infection or C diff. And if you do not know what C diff is, please consult Dr. Google.

“But two percent is pretty small, right?”

Sure, the number two is small. But let me better demonstrate the current impact by a simple math problem: What is 2% of $500 million? Answer: $10 million. Do you find that number to be insignificant? If so, let me know, I have a bank account I would totally love for you to donate an insignificant amount of money towards. Hospitals, however, do not find this number insignificant; they find it terrifying. They have invested large sums of money to play the “value game” and shove it down the throats of every single employee all because they are being scored on the above arbitrary measures and being given a final number that dictates where they fall in the spectrum of “providing value”. For those that are in the health care field, this is where the HCAHPS scores come into play with “patient experience”. This is why you are hearing administrators drone on and on about going from an 8 to a 9 in patient satisfaction because if you drop too low you lose. This is why even if you do your job perfectly you are a failure due to circumstance you cannot control because they are irrelevant to your goals. This is why you are a glorified, narcotic-dispensing, note monkey.

It should be noted that the scores for value-based purchasing are completely relative to the scores of other hospitals. If everyone is scoring 97% on a metric, then the only way to see any benefit may be to score 98.5% which is challenging even by Tiger Mom standards. CMS may periodically change the metrics around to keep it interesting but, contrary to popular belief, most hospitals are already doing a pretty good job at that whole “keeping people alive” thing. Eventually, there will be a ceiling in which there can be no realistically obtainable improvements. At that point, stagnation occurs and innovation through desperation will lead to some rather interesting creations. Ultimately, the best that hospitals will be able to look forward to is to simply not lose more money from the VBPires.

But it doesn’t end there; It is just the beginning. If this program was only going to max out at two percent, it may not be so bad. There are always ways to reallocate resources to stem the bleeding. Burwell and her HHS minions have much greater plans and have made it a point to be rather transparent to her victims through the New England Journal of Medicine.

II.

In 2015, Burwell wrote an article laying out her plan. Titled: HHS efforts to improve U.S health care, Burwell discussed plans for tying a larger and larger percentage of Medicare payments, whether it be fee for service or bundled payments, to the concept of “quality”. How much? Well, Burwell wants 85% of fee for service payments linked to “quality” by 2016 and 90% of those payments linked by 2018. At the time this article was written, only 20% was tied to “quality”. Regarding the alternative payments (read: bundled payments), Burwell has decided to tie 30% of those payments to “quality” by 2016 and 50% by 2018. Can you take a wild guess at what the purpose of those rather disparate percentages could be? Can you feel the walls closing in around you? No? Well, the hospitals probably can. You will too, in time.

Burwell proceeds to further lay out her sinister plan of throttling the health-care system through various different means. Most of her plan is laid out in double-speak, so it does take some effort at translation, but I will try and do the best I can. First up, Burwell states she intends to “create an environment in which hospitals, physicians, and other providers are rewarded for delivering high-quality health care AND have the resources and flexibility to do this.” Sounds great, right? Sounds aspirational. This phrase probably gives some people the warm-fuzzies and fills their heads with ambiguous thoughts of “fixing health care”. If this is you, you are an idiot. Or at the very least, really, really gullible. You must keep in mind that Burwell and the HHS are not out to “fix” health care; they are out to make it cost less. That is the bottom line; that is the goal of this reform. This is evident by the next paragraph which goes onto talk about creating further alternative payment models for cancer treatment and other specialty care. (For those not in the know: cancer hospitals/centers are currently DRG-exempt and can be rather lucrative and off-set costs of other less sexy conditions like COPD, pneumonia, liver disease, etc) Again, this sounds rather aspirational and reasonable until you find yourself faced with the indisputable fact that treating cancer is expensive as hell! There is a lot of money that goes into treating cancer, from the bench research and clinical trials to the manufacturing of next-generation gene-specific cancer therapies, the cost associated is astronomical. However, save for a few therapies and specific cancer diagnoses, most treatments for cancer provide little more than a few extra months of life with questionable quality. Hundreds of thousands of dollars spent to have an extra few weeks to few months, the majority of which may be spent in a hospital setting, is the very definition of current cancer treatments.

Can you see it yet? Burwell is not out to improve the “quality” of cancer care. The current “quality” of cancer care is already exceptional and to some degree decadent. This decadence is what needs to be extinguished. But the Powers-That-Be at HHS are smart enough to know they cannot outright ban costly treatments; that is not the American Way. The backlash from a move like that would bring the whole charade crashing down. Instead, Burwell and Co, are quickly creating an environment where the hospitals, and to some extent the physicians, will be forced to make the decision on how best to triage care relative to financial solvency. The government may never explicitly state “Don’t use this treatment, it’s expensive as hell and a poor use of resources!” but they sure as hell will refuse to cover the cost of those expensive treatments under the guise of “bundled payments” which will ultimately leave the physician weighing the pros and cons of appropriate resource utilization against the life of their patient. How does one explain to a patient, and their grieving family, that nothing further can be done because no one will pay for it? How do physicians continue to be physicians once “accountant” becomes a part of their job title? The answer: “It doesn’t matter. It costs less.” –  Burwell while drinking fresh virgin blood.

“Well, it has to happen, doesn’t it? Haven’t we gone a little overboard on all these cancer treatments anyways? You even said it yourself, they only get a few months at best.”

Agreed, but it’s not just cancer treatments. The above scenario applies to ALL chronic diseases, or at least will in time. How will the treatment of advanced heart failure or COPD change in the near future? Will we continue to offer LVADs, frequent hospitalizations for diuresis, lung transplants, or heart transplants? Will we set a limit on the number of admissions one is allowed over three months for their chronic conditions? Will research come to a halt due to lack of funds and profits for new therapies? (Europe may be able to answer that question for us) And again, none of these answers will come from CMS/HHS/Burwell and company; they will be reluctantly answered by the hospitals and physicians under the whip of the insurance companies and government. This, in turn, will change the very culture of those involved in providing health care. Altruism, despite its several flaws, is a primary motivator for many in the health care field. How will that change once you fully transform medicine into an “industry” with the focus becoming the bottom line? Will you still attract the intelligent and independent thinkers that have so often gone into the field? Or will you attract customer-service oriented, guideline-directed, intellectually-throttled, bureaucrats that see the patient’s cost as their fifth vital sign? The change will be gradual but there will be a change. Prepare yourself.

III.

For many in the health care field, the future of health care is considered “uncertain”; this is a self-imposed deception to shield themselves from the truth. The future of health care, at least at this time, is very certain and viewed with variable degrees of optimism relative to one’s station in the health care industry. For those in Burwell’s boat, flying the Jolly Roger and riddled with scurvy, the future looks rather bright. Costs will go down, health care will become more “accessible”, and hospital and health care systems will make great efforts to demonstrate their “value”. For those in the trenches, the future is far less bright and will likely consist of a never-ending stream of best-practice advisories in the form of unavoidable pop ups through the EHRs (electronic health records), increased focus on “customer service” and satisfaction scores in the form of yearly modules and quarterly reviews, as well as increasing scrutiny over documentation and hospital-encounter costs per physician. For patients, your care will likely dramatically change and your “satisfaction” will likely be further pursued to your detriment. In some ways, it is already happening. I cannot tell you the number of patients I see, transferred from other hospitals that were bound and determined to kill them, and hear nothing but praise about that transferring facility due to their expansive and highly palatable meal options. It did nothing for their disseminated histoplasmosis, but I’m sure it still received excellent reviews. But while your Salisbury steak gets more palatable, your options for treatment will gradually be restricted, and you will ultimately be provided with less avenues in which to delay your death. Intensive care services will gradually be rationed and we will likely see a system not too dissimilar to Brazil where litigation is often used to acquire an ICU bed due to limited resources. Palliative care will continue to become more important. Hell, it already is becoming more utilized for various reasons, one of which is spelled out by the advisory board as “saves hospitals thousands of dollars per inpatient case and reduces ICU length of stay, contributing to cost savings and freeing up of capacity”. And don’t get me wrong, palliative care is extremely important, especially in our current health care system, but do not keep expecting that it will forever remain a choice to “keep fighting” as the baby-boomer time bomb continues to tick down. The best one can hope for is that they are wealthy in the future because “executive medicine” isn’t going anywhere anytime soon.

“Isn’t this all a little extreme? Besides being a total buzz-kill, you seem to be taking this pretty far.”

It is extreme. And I am a buzz-kill. But this is the plan taken to its logical conclusion with each step being revealed at the very moment the path behind you has fallen away. Many hospitals and health care systems were lured in with the prospect of financial gain through actions which many were already pursuing; I assume the thought was that this would be easy money. In contrast to this opportunistic stance taken by many health care systems, physicians seemed to take a more fatalistic approach. They began accepting those changes as inevitable and, because physicians are cowards, never made any real attempt to resist. The AMA, which is supposed to be a lobbying group FOR physicians, showed where their true allegiances lay by strongly supporting Obamacare for reasons which had nothing to do with improving the lives of physicians. What did it have to do with? Money. So, here we are, about five years or so into this Brave New World, and the future is starting to come into view over the horizon. Despite President Meme Trump threatening to dismantle Obamacare (he won’t, at least not significantly), the wheels are already in motion, the gears are turning, and this Kill-Dozer of health care reform is about to turn the corner on a busy street and start making metal pancakes.

And you will get what you pay for.

Your doctor probably hates you

6:00 – Arrive to work.

6: 15 – Gather list of patients. 20+. Six new ones. Only three that need to be here.

6: 25

RN: “Patient in room 4 is requesting more pain medications”

MD: “For what?”

RN: “Their back pain.”

MD: “What are they getting now?”

RN: “Percocets. They want something IV. They say it works better”.

MD: “…. No.”

RN: “Ook…”

6:30

RN: “Patient in room 4 wants to talk to you about their pain.”

MD: “I will see them in a little while.”

6:45

RN: “Patient in room 10 wants tylenol and none is ordered. Can you order some?”

MD: “Yeah, sure”.

6:50 – *Admission pager* Admit from ED. Room 3. Intractable abdominal pain. MD: (God damn it…)

7:00

MD: “So what brings you to the hospital?”

Room 3: (half asleep) “I’m having horrible abdominal pain, doc! It’s like 12 out of 10! It’s all over! I can’t eat! I’m vomiting a lot!”

(Empty food wrappers noticed on bedside table)

MD: “Were you able to eat any of that?”

Room 3: “No, I tried. But couldn’t keep it down. My pain is so bad right now!”

(Review chart: Patient admitted multiple times a month for same complaint. Extensive work up shows nothing. Patient frequently demands IV pain medications)

MD: “Ok, well, we will bring you in and watch you for a day or two.”

Room 3: “Can you tell the nurse to bring me more IV pain meds?” (eyes still closed)

MD: “We will give you pills while you are here…”

Room 3: “But I’m so nauseous! I need IV!”

MD: “We will give you anti-nausea medications”

Room 3: “But pills don’t work for me! I’m in so much pain!” (eyes still closed, covers over them, stretched out comfortably)

MD: “I’m not giving you IV at this time. We can re-evaluate later”

7:23

Room 4: “Doc, why can’t I have IV pain medicatons?! My pain is so severe! My back hurts so badly! These beds are so uncomfortable!”

MD: “Do you have back pain normally?”

Room 4: “Yeah”

MD: “And what do you take at home?”

Room 4: “Well, nothing. Or tylenol.”

MD: “Then why do you need IV pain meds here?”

Room 4: “Well, because these beds are uncomfortable and my pain is worse here. I just need a pain shot, doc! Just give me one pain shot and I will keep with the pills.”

MD: “IV narcotics are not indicated for chronic low back pain”

Room 4: “But you don’t understand! My pain is 12 out of 10! I can’t get comfortable! Just one shot! Please! (breakfast tray in front of patient, half gone already)

MD: “No. You need to get up and walk around.”

Room 4: “But it’s hard for me to get up” (BMI 42 with 8 self-inflicted co-morbidities)

MD: “We will have physical therapy help you. Otherwise, your blood pressure seems to be improving, your blood sugars have gone down, your oxygen requirement is going down with treatment of your pneumonia, we have arranged for home health care to come to your house and assist you with medication management and daily activities (which you have no excuse to not be able to do at the age of 43), we have set up a primary care physician for you, and we have started the approval process for medicaid (as you seem to be unable or unwilling to do this for yourself and have no insurance). Is there anything else we can help you with?

Room 4: “But I really just need a pain shot!” (MD leaves room)

7:28

Room 7: “My sickle cell pain is horrible!! I need more IV dilaudid!” (playing on cell phone with multiple food trays on table and TV blasting)

MD: “You have been here for 4 days, your labs are improving, you are eating and drinking fine. I am not increasing your IV narcotics. In fact, starting tomorrow, we will begin weaning your medications down.”

Room 7: “But I’m still having my sickle cell pain! It’s horrible! I can’t sleep or eat or ‘nothin! You don’t understand! You don’t know! No one treats me fairly here! If I don’t get more pain medications, I’m going to leave!”

MD: (Please God, Please leave! Please leave! Please leave! Go verbally assault someone else! Dear God, please let them leave!) “Well, I’m sorry you feel that way. But we are going to be sticking with your pain plan and will start weaning you down tomorrow. If you feel that you would be better served somewhere else, you are more than welcome to leave whenever you would like.”

Room 7: “I’ll think about it” (Never leaves)

7:34

Room 9 (62 year old patient that is neurologically devastated from massive stroke with progressive multiple sclerosis and intractable seizures. Baseline activity is breathing, random eye movements, and occasional sighs)

MD: “How are things today?”

Room 9 family member: “Doctor, I have some concerns.”

MD: (Christ…what now…) “Ok”

Room 9 family member: “I’ve been noticing that my (insert mother, father, son, daughter, niece, grandmother, or next door neighbor) has been having some occasional twitching in their arm. And then I notice that their blood pressure will go reeeaaallllyyy high for a little bit and then go back down. And then occasionally they cough. What is that?”

MD: “How high is the blood pressure?”

Room 9 family member: “Like the top number is like 150!”

MD: (……) “I do not think I have a definitive answer for you right now, but we will keep an eye on it.”

Room 9 family member: “How do you not know what is going on?! You’re a doctor!”

MD: “These are very nonspecific findings so it is very difficult to say if this is something to be concerned about or not.

Room 9 family member “Well, I think we need to do a scan of their brain.”

MD: (Their brain is dead and so are they) “We will look in to that…”

7:41

Room 11 (52 year old morbidly obese male with type two diabetes here for recurrent infection in his foot from uncontrolled blood sugars and poor follow up with podiatrist)

MD: “How are you doing today?”

Room 11: “Hey doc, when am I gonna get breakfast?”

MD: “I do not know. I do not control that.”

Room 11: “Well, they need to bring it soon. I’m starving! (BMI 41) Can you ask the nurse to get me something to eat?”

MD: (This is why I went to school???) “We’ll try to get you something when we can. But to update you, your foot is starting to look better, however you will need another 5 weeks of IV antibiotics to treat your infection. We will have a line placed in your arm, arrange home health care, and have you scheduled with infectious disease for follow up.”

Room 11: “Uh huh. Hey doc? Is there anything you can do about the food here? They totally messed up my dinner order last night and the food here tastes terrible.”

MD: (The last thing you need to do is eat…) “You should speak to dietary.”

7:52

Room 15: “Hey Doc! When can I leave?” (Has infective endocarditis, active IV heroin user, and needs to complete therapy at a nursing facility)

MD: “As soon as we have a final plan for your antibiotics and placement on discharge”

Room 15: “Hey Doc? Can I get more pain meds?”

7:57

Room 16: “FUCK YOU! YOU CAN’T KEEP ME HERE! I HAVE RIGHTS! YOU’RE NOT EVEN OLD ENOUGH TO BE A DOCTOR!” (Demented gentleman with no family requiring guardianship currently being treated for infection)

8:10

Room 17: “Doc, I really need something for my anxiety. It’s really bad right now. I think I need xanax.” (Comes in with vague abdominal pain, currently resting comfortably in bed)

MD: “I am not giving you xanax. They are addictive. I will give you hydroxyzine if you want”

Room 17: “Well, how about ativan? My anxiety is just really bad doc!”

MD: (You can’t medicate life. How have you made it this far?) “No. I will order hydroxyzine.”

8:15

Room 18: “Doc, I need more pain medications!”

8:18

Room 19: “Doc, these nurses don’t know what they are doing! I hit my call light like 8 times for IV pain medications and they just did not come fast enough! Can I talk to patient experience?”

MD: “Well, good news! We planned on discharging you today as you seem to have improved substantially. You will be able to sleep better in your own bed.”

Room 19: “I don’t know doc. I feel like if I leave today, I’m just going to come right back to the emergency room” (clearly veiled threat)

MD: (I’ve just entered into hostage negotiations with an asshole) “So what are you trying to say?

Room 19: “I think I will be better tomorrow.”

MD: (Two decades of schooling….) “Fine….”

8:21

Room 21: (refused all blood draws and medications) “I just want to sleep! No one let me sleep all night”

MD: (THEN WHY ARE YOU HERE?!?!?!?!?!) “We will check back later…”

9:35

RN: “Room 16 lost his IV. And he is refusing any other sticks. What should we do?”

MD: (Let him rot in hell and die slowly!) “I’ll see if we can get him on oral antibiotics…”

10:15

Case Manager (CM): “Hey Doc, the insurance company for patient 12 is refusing to pay for his stay and wants you to do a peer to peer for further review.”

MD: (What am I?) “When do they want to do it”

CM: “They will call you between 12-5pm”

MD: “Great.”

11:24 – (Pager message: Reminder – Faculty meeting at noon! Free lunch.)

12:00 – Faculty meeting

CFO: “Glad everyone could make it! Now done to business. I want to talk about the hospital’s readmission rates, patient satisfaction scores, length of stays, and ways in which we can improve all of these elements.

MD: (Close down the hospital and open up a hotel with food court instead)

CFO: “There are some big changes coming down the road with reimbursements from Medicare and other major insurance companies and we really need to get our numbers up if we want to be competitive. Currently, patient’s are ranking us about an 8/10. But we need to get to that 9/10 or 10/10 or else we simply won’t make those benchmarks for receiving full compensation! I know we can all do it if we work together!

MD: (Stop providing medical care and invest all money into food and narcotic sales because who gives a shit if every patient dies just as long as they are high and well fed)

12:45 – *Admission Pager* ED admit. Room 19. Altered mental status.

12:55 –

Room 19 (88 year old demented female with no family in the room)

MD: “Hello. I’m Dr. X. What brings you to the hospital?”

Room 19 (staring blankly and not answering questions)

MD: “Are you in pain?”

Room 19 (falls asleep)

MD: “Ma’am, do you know where you are?”

Room 19: “It’s Easter!”

MD: (I should have gone into radiology….)

13:32

RN: “Hey Dr. X, Room 9’s family wants to speak to you.”

MD: “About what?”

RN: “They said the patient is having a seizure and want to speak with you right away!”

MD: “Is the patient having a seizure?”

RN: “I don’t know. I have to hand out pain meds right now. They just called out from the room.”

MD: “…On my way….”

13:35

MD: “I heard you have concerns?”

Room 9 family: (now multiplied) “Yeah, so, we saw some more twitching. We think they are having a seizure and we want neurology to come see them.:

MD: (The patient is a god damn vegetable and nothing will change that) “From what you have described, these seem like simple jerks. They do not seem to have any evidence of seizure at this time.”

Room 9 family: “Well, we FEEL that they are having seizures. We want neurology to come by”.

MD: (Can I see your medical degree?) “I will ask them to stop by…”

14:25

Neurology: “Hey, Dr. X? This is neurology. We got your consult. I reviewed the chart and don’t think there is anything we can really help with. Do you think they are actually having seizures?”

MD: (OF COURSE NOT!!) “No, but the family is concerned and would like your input.”

Neurology: “Well, you know, you are also a doctor. I think you should just go back by and try and re-educate them some.”

MD: (FUCK YOU! FUCK YOU WITH A RUBBER HOSE! JUST DO YOUR GOD DAMN JOB!) “I think they would like to hear it from you.”

16:30 – (Three more admissions from the ED: COPD exacerbation in a 60 pack-year smoker, end stage renal disease on dialysis that needs dialysis and missed the last 2 sessions for nonsensical reasons, and an acute alcohol withdrawal)

16:45 – Clinical Documentation Specialist (CDS): “Hi, Dr. X? This is Sherri from CDS. We were reviewing your charts and we were hoping that you could clarify a few things in your notes. You mentioned hypoxia in one note, does this constitute acute hypoxic respiratory failure or chronic hypoxic respiratory failure? And do they have type two diabetes with hyperglycemia or it is well controlled? These are all important measures that need to be appropriately documented to help capture the the severity of illness for all admitted patients.

MD: (I am a glorifed drug-dealing secretary) “I will try to make the appropriate changes…”

17:35 – *Admission pager* ED Admit. Room 14. 74 year old female with fall requiring placement.

1800 – Day is done. Six more to go. At least there is alcohol….