Happy Labor Day 2019

I decided to keep posting a Labor Day greeting to my fellow physicians. I’ve been doing this since 2013 and previously linked to all of those pages. Now there is a search feature in the upper right corner of this blog and you can just search on Labor Day if you are interested. My post this year is truncated based on the fact that very little has changed since my fairly comprehensive post 2018. If you will look up that post I comment on physician productivity, the EHR, pharmaceutical benefit managers, managed care and health insurance companies, maintenance of certification, and burnout in some detail. The advances in these areas have been too trivial to comment on in terms of either progress or the chronic lack of progress. I am sure that some organizations would like to debate that. The APA for example would point out that a health insurance company was successfully sued for failing to reimburse care for mental illness. The judge in that case actually made some fairly critical remarks directed at the managed care company, but on a day-to-day basis the average psychiatrist and the patients they are treating notice nothing but continued oppression.

Psychiatrists and their patients traditionally have fewer resources than other physicians and standard medical and surgical care. The overwhelming signs of this include jails being used as psychiatric holding tanks (I refuse to consider them hospitals) and the ongoing bed shortage. That bed shortage leads to overcrowding in emergency departments and a tendency for patients with mental illness to be the only ones discharged untreated from emergency departments. That often happens after they’ve been held there without treatment for days at a time.

There is something basically wrong with a government and political system that refuses to provide humane and equitable care for people with mental illnesses on the one hand and blames them for societal problems on the other. Just earlier today in the context of yet another mass shooting I heard the President describe the perpetrator as being “very mentally ill”. This occurred after a recent visit to the White House by a National Rifle Association representative. During that visit the president was talked out of advocating for universal background checks and the party line became “blame the mentally ill for mass shootings”.  It appears that the executive branch has a red line that they won’t cross when it comes to rational gun policy and a second red line that they won’t cross when it comes to providing equitable treatment for people with mental illness and addictions.

I think that is a relevant Labor Day observation for physicians because these irrational policies affect all of us. As psychiatrists we see very mentally ill people go in and out of hospitals and administrators pressure us to get them out before they are stable.  They are typically discharged to minimal outpatient services. We experience the tension of trying to get people off of inpatient medical and surgical units or out of the emergency department to appropriate psychiatric settings when there are none. Our physician colleagues feel that pressure. We all recognize that we were not taught to treat people this way in medical school. The only reason we do is that physicians no longer control the practice of medicine. Business administrators and people with no medical qualifications do control the practice of medicine. I repost the graphic here that was sent to me by David Himmelstein, MD who also gave me permission to use it on this blog.  Just getting rid of all of that bad management would result in saving a trillion dollars and bringing US health care costs in line with the country with the second highest per capita costs - Switzerland. 

It is clear to me that the problem with the physician work environment - the place we all labor intensely for too many hours - is a problem with administrators. Never before in the history of medicine have we had so many administrators telling us what to do. The graphic clearly illustrates that.  As working physicians we all know what that means.  We know it means when an administrator suddenly has a “great” idea that is not based on science or medicine and we all have to live with it for months or years. We all know what it means when a group of administrators suggests that we are not getting patients out of the hospital fast enough even when they are still ill.  We know what it means when we have a lengthy meeting with administrators for our “input” only to learn that they didn’t really want our input they just wanted to tell us how things were going to be for the rest of our career. And if you are as old as me, you might recall a time when medical departments were run by physicians and they had business managers who took care of business. In those days there were clear boundaries between medicine and business - not like it is today.  We are well past that point now.  The practice environment is a boundaryless morass of business people telling physicians, pharmacists, and patients what to do.  The rationale for this morass (cost containment) is no longer visible - probably becuase this model has failed miserably. Instead there are massive costs and a massive transfer of those direct costs to patients and indirect costs to physicians.

It has also resulted in the lowest possible quality of care.  The quality of medical care and how that is measured became a secondary consideration when businesses took over medicine.  A clear example is the treatment of depression on an outpatient basis. One of the standards promoted by the managed care industry is measurement based care using a scale like the PHQ-9 for ongoing assessment.  Unfortunately this process lends itself to using the measurement as a diagnosis and rapid route to treatment with antidepressants. Several approaches to depression including subsyndromal depression in primary care settings are ignored and PHQ-9 scores are followed as a measure of quality improvement.  This is the type of gross oversimplification that occurs when clinical medicine (1) is ignored in the context of businesses claiming that their measurement process is superior.

These inefficiencies in the day-to-day work of physicians are presented as improvements that we should all be happy to go along with.  In many cases administrative catch phrases like: "Change is good" accompany the poorly thought out and unscientifically implemented policies. The practice environment for physicians will only improve if the  bean counters no longer run medicine.

Until then Labor Day will be just that.

George Dawson, MD, DFAPA




Reference:

1: Arroll B, Chin WY, Moir F, Dowrick C. An evidence-based first consultation for depression: nine key messages. Br J Gen Pract. 2018 Apr;68(669):200-201. doi: 10.3399/bjgp18X695681. PubMed PMID: 29592945

The Drive To Do Good Work When No One Is Looking

Himmelstein and Woolhandler have hit it out of the park again.  This time in a seemingly modest letter to the editor in the weeks JAMA.  Although their main point was the perversity of pay-for-performance incentives in the final paragraph they make this observation:

"We fear that pay-for-performance incentives will undermine the mindset required for good physician practice (ie, the drive to do good work even when no one is looking)." (p.304)

This is a quote that everyone should pay attention to because the so-called financial incentives that have been with us for years are highly problematic and have not contributed a thing to the quality of medical practice.  The first consideration is whether or not what Himmelstein and Woolhandler say is true?  It has  clear validity.  Physicians are trained to do the right thing in terms of individual patient care.  That involves dedication and adhering to professional standards like continuity of care.  Physicians as a group are driven people.  They will work past the point of exhaustion especially f they feel that they need to follow up a certain problem for a certain patient.  Many primary care physicians are working 24/7 in order to keep up on paperwork, labs, prescriptions, and test results.  It is not possible to "call it a night" if there is a critical lab value that needs to be evaluated or a patient that needs to be informed.  There are plenty of decisions in medicine that have a high inherent degree of uncertainty and that can lead to sleepless nights searching for an answer.  The electronic health record (EHR) has increased that burden.  I have colleagues that tell me that every morning when they walk into clinic they may have as many as 200 lab results waiting for them in the EHR.  If they do not have assistance with triage, they have to personally view these results and do something about them.  They may also have to respond to direct e-mails if they are affiliated with a plan that allows patients to directly e-mail their physician.  That is before they begin seeing a full schedule of patients and seeing urgent problems that day.  Responsibility to the patient is what drives this process not trivial financial rewards and penalties based on illogical outcome measures.

Why all of the confusion?  I think the problem can be analyzed at several levels.  At the antiphysician level there are obvious forces in play that want to coopt the professionalism of physicians and make it seem like without a business and government bureaucracy that physicians would be out of control.  In other words the public needs the government and big business to control physicians.  This was the essential rhetoric that led to the managed care era in the first place.  Physicians were greedy, did too many procedures for financial gain, and needed to be managed by a large and expensive business administration.  The managed care theory completely ignores two basic facts.  The most obvious fact is that three decades of managed care has not controlled health care inflation or increased health care access as promised.  That is compounded by the fact that many of these companies currently own all of the means of production including the doctors, hospitals, labs, and MRI scanners.  But nobody has accused them of being greedy.  The second fact is that independent review of the problem from the 1990s showed that the political theory that physicians were engaged in massive overutilization was so inaccurate that they closed the government review program down.  How often does a government program get shut down?

The assault on the professionalism of physicians reached new heights in the 1990s when the federal government under the Clinton administration decided that fraud conducted by physicians was also a major driver of health care inflation.  Armed with billing codes and guns, it was an era where FBI agents were trained to enter offices, get the records and determine of the documentation matched the billing code.  There were several high profile cases where the Department of Justice decided that "fraud" had occurred.  The fraud they were referring to in one of the landmark cases was attending physicians not writing an extensive enough note in addition to whatever note the resident physician wrote.  That led to about two decades of excessive and unnecessary documentation.  Right up until the point that the federal government could grant this power to managed care companies and give them the power to deny payment and demand reimbursement back based on their interpretation of whether the documentation supported the service provided.

Throughout all of this heavy handed political intervention physicians have continued to do the right thing and maintain their professionalism but the rhetoric has taken a heavy toll.  It is not unusual for a person to enter a health facility owned by a managed care company and see some credos from the physician code of conduct plastered on the walls in an elevator.  When that happens the company is generally sending a clear message: "It is only because of us that medical professionals behave in a professional manner."  Nothing is farther from the truth.  There is no carrot or stick that keeps a neurosurgery residents on call in a hospital every day and night for a year at a time.  There is no carrot or stick that keeps psychiatrists treating aggressive patients who continually threaten and may try to assault them.  There is no carrot or stick that keeps physicians going to the point of exhaustion and to the point that they realize that they are clearly spending much more time caring for other people than their own families.  A typical response from people with those scenarios is either: "You don't have to do that." or "You don't have to work that hard."  Physicians currently waste 20-30% of their time on bureaucratic nonsense dreamt up by people who themselves do not provide direct patient care.  In the time left they are expected to see more patients and do more documentation than physicians have ever had to do at any point in history.

I don't mean to suggest that there are not people in all walks of life who do the right thing at work.  As I am typing this I recall my father describing one of his coworkers sometime back in the 1960s.  My father was a railroad engineer.  He drove locomotives of both the diesel and steam variety.  The railroad world in those days was a parallel universe that I would occasionally get a glimpse of.  Massive buildings smelling of diesel fuel storing massive, loud, pulsating diesel locomotives.  They just let them run 24 hours a day.  My father and a group of his railroad colleagues were rebuilding the porch on our house one day and they were all talking very positively about a car knocker who worked for the same railroad.  A car knocker is a rail car repairman.  They keep trains rolling.  All of my father's co workers and my father all praised this person because at work he always seemed to do the right thing.  The quality that they seemed to admire the most was that he would always attend to part of the task even when he lacked a certain skill that required him to pass part of the job on.  That was apparently a rare trait and that was my first observation of the quality of doing good work and how it was widely admired on its own merit.  No financial reward or employee of the week parking spot.  Just the mostly hidden admiration of your coworkers.

To me the most perverse aspect of physician "incentives" is that they are already earned by physicians.  In the managed care world, groups of physicians are subjected to a "holdback" of anywhere from 5-15% of their gross billing.  The idea is that unless the entire department makes the productivity expectation (an arbitrary number set by an administrator) the money is lost.  If the financial target is made money "awarded" was already earned.  There are no bonuses only penalties.  A lot of the incentives for reporting various measurements or complying with the next bureaucratic hoop are in the 1-2% range.  That is important only for the bean counters described in the letter.  Make no mistake about it - they will exert whatever pressure they can on physicians to "make" that 1 or 2%.  And make no mistake about it - twenty years that bean counter job would not have existed.

And there still would have been physicians in hospitals all night long trying to do the right thing and not caring who knows about it.

George Dawson, MD, DFAPA

Himmelstein DU, Woolhandler S. Physician payment incentives to improve care quality. JAMA. 2014 Jan 15;311(3):304. doi: 10.1001/jama.2013.284475. PubMed PMID: 24430325.

Additional Clinical Note 1:  Some health care settings have really taken the incentive programs to an absurd level.  Mandatory pep rallys for the employees, employee of the week or month awards and the expectation that everyone generates a huge amount of false enthusiasm for these rewards.  At the same time the confidential 360 degree performance review is the latest tool that administrators can use against physicians.  In this exercise a panel of anonymous multidisciplinary coworkers rate physicians on a number of non-medical standards (like how well they support corporate standards).  The performance review is basically a combination of subjective impressions that have very little to do with the physicians medical competence.  It is all part of the corporate beauty contest that is passed off as medical quality.  Most managed care companies seem to not know the meaning of the word.

Additional Clinical Note 2:  Governments and managed care companies are never at a loss for measuring things that are completely irrelevant to the provision of quality medical care.  The best example is patient satisfaction surveys.  If you are ever handed one as you leave the hospital or clinic the first question to ask yourself is whether the questions seem familiar.  If they do it is because your were scripted.  That means that the person you just talked with covered a number of bullet points corresponding to your survey.  It is designed to maximize the score on that satisfaction survey.  These results are often linked with incentives.  But nobody ever talks about the fact that you could have received the best care in the world and may not been able to complete a survey when you left the hospital.