Modern Medical Management - The Myth of Sharing

Any casual reader of this blog will note that I don't really find any value in the myriad of management practices that have been added to medicine since businessmen and their friends in government have taken over.  The only reasons that these practices have been added is strictly political and rhetorical.  Nothing has been overhyped as much as management adding value to medicine with so few results.  Nothing has done quite as much to detract from the quality of care than these same business practices.  At this point they have become as entrenched as gun legislation and will be every bit as intractable. These problems are very difficult for the typical consumer/patient to see.  The obvious points of contention are insurance company denials either for medication or medical care.  They peaked in the 1990s when managed care companies thought that they would just put specialists out of business and had primary care physicians acting as "gatekeepers".  If you are old enough you may recall having to get a referral from your primary care physician to see specialists, for various services. and in some cases even to go into an emergency department.  It took them a while but these businesses learned that being that transparent in denying care was probably not in their best interest.  It also created a large burden on primary care physicians who were now uncompensated reviewers for the insurance company business practcies.  Eventually that system was scrapped in favor of shifting financial risk around - some to consumers and some to physicians and physician groups.  There are many ways it can happen, I thought I would provide a few examples below.

Managers like to use a shared decision making model in their manipulation of physicians.  I guess they don't consider physicians to be particularly bright people.  I don't know if that happens when you are socialized in the business world and automatically consider your decisions to be the best based on scant data, a lack of measurement standards and perceived quality of a good idea.  Whatever the reason, the approach generally only works because the physicians have no leverage.  Consider the following example.  Ten physicians are in a group providing hospital coverage for admissions to a community hospital.  It can be any specialty.  They are working a 7 days on and 7 days off model and each of them typically admits 10-14 patients per day at work.  They are stretched to the maximum so that anyone requiring emergency leave seriously disrupts the schedule.  Their colleagues are expected to cover.   The administration would like to open an 10% additional bed capacity and meets with all of the physicians about this to problem solve over how that might happen.  The physicians are asked the question: "We are here to all figure out how to increase the number of admissions by 10%.  Do you have any ideas about that?"  That leads to a general discussion of how the physicians are overworked and already spending too much time from home on the electronic health record.  A consensus builds and the physicians say they need more staff and staff to cover unpredicted absences.  At that point the administrator states: "No - I guess I didn't explain myself very well.  We are here to decide how to provide more services without increasing the cost by hiring new people."  The physicians finally get it.  Sharing in this case means, I will ask you for your input, but it is meaningless and I will require that you work harder even though you are probably burned out right now.

Another popular sharing model where physicians share more than anybody else is financial risk sharing.  The first introduction was when RVU productivity units were introduced.  The initial administrative argument seemed to be that not everyone was carrying their own weight.  The RVU system was portrayed as being inherently more advantageous to those people who were really productive.  It would allow them to make more more than the slackers in the department.  That was a good theory to try to appeal to physicians competitive natures, but in most departments - schedules and productivity was already saturated.  There were no slackers.  That point goes to the administrators.  The second risk sharing introduced was the "holdback" model.  This said that 10-15% of everyones' productivity would be held back until it could be assured that the production figures were met and then it would be released to the physicians in the group.  Keep in mind this was money that was already billed and earned.  There was no similar "holdback" from administrators or other personnel.  A take off on this risk sharing was getting physicians in administrative meetings and showing them endless spreadsheets of overhead costs and how much they would have to "produce" in order to get either their holdback or some other form of reimbursement.

The ultimate form of risk sharing today seems to be the contract that comes in and puts everyone at risk by not even recognizing the physician billing.  In this case the insurer comes in and says - this is how much we will pay you on a per diem basis to cover these patients for various problems.  You agree not to charge use anymore than than - no matter how much care each one of those patients needs.  This last model is the most insidious.  It caps any insurance payments (losses) and puts any physicians and their clinic at complete risk for catastrophic loss but more importantly it is a war of attrition.  With this model as the only source of funding, it allows administrators to view physicians as "costs" rather than resources and eliminate them, underfund them, overwork them, and burn them out.  It is a tried and true pathway for how managed care organizations using this model can adversely impact the quality of care in every organization they contract with, but especially the ones that don't understand corporate doublespeak.

Too many of my colleagues tolerate corporate doublespeak in management systems.  They don't seem to understand that risk sharing does not really mean that anything is shared.  It means that they are left holding the bag.  These same systems tell us how "younger physicians" are more accepting of these models.  Medical professional organizations and specialty boards are talking the talk.  We have the American Psychiatric Association talking about various collaborative care models where psychiatrists don't need to see patients any more.  The speciality boards have designed a number of expensive and complicated performance metrics that have no basis in reality and CMS (Centers for Medicare and Medicaid Services) has done the same.  It is hard to imagine that when I started out in Medicine we did not have to deal with all of this administrative fantasy.  We went to work each day and it centered on the facts, patient care, and the medical science of the day -

Not what somebody forced us to believe for a few months at a time while they were wasting our time, energy, and money.

  

George Dawson, MD, DFAPA

Watson Replacing Radiologists?

I like reading the Health Care Blog.  It typifies what is wrong with the management of the American Health Care system and I suppose blogs in general.  It is a steady stream of bad ideas and political rhetoric.  The best recent example was a little piece about radiologists called Will Watson Replace A Radiologist - Ask A Radiologist.  Radiologists either don't read this blog or they can't be bothered since the only comment at this point is from a rheumatologist on the necessary consultation and collegiality with radiologists.  The author of the main article is taking the perspective of being both threatening (Can the IBM Watson machine acquire the image reading capabilities of a human radiologist by "reading" a large set of clinical images and reading them at a much faster rate than a radiologist?) and advising (The only way that radiology will survive is to demonstrate their value to patients and colleagues by connecting with them?).  The author's conclusion is very explicit: Connect or be replaced.

Over the past thirty years my experience with radiologists has been positive and in some cases outstanding.  That dates back to the early days of being the medical student or intern responsible for carrying a stack of heavy and awkward films around.  I remember not having a film on a Cardiology rotation and regretting it: "Mr. Dawson - what made you think it was not a good idea to have the chest x-ray of this patient with mitral valve disease?"  From that point on radiologists were my friends.  That was an era before there was a lot of managed care penetration and I always rotated at public  hospitals and VA hospitals anyway.  You could always find a radiologist back in the dark confines of a reading room.  The interns and residents had certain staff members that were the go-to staff in terms of teaching and also amazing observations.  They always pointed out what we were missing.  They collected teaching files and teaching cases for us to learn from.  Reading rooms could be bizarre places in those days.  Very large films clamped on reading boxes.  In some cases entire rows of films - 10 to 12 wide, could be rotated on a belt device.  The radiologist would need to recall when they saw the film and press down on a foot pedal until the correct film popped up.  On many days row after row of films would need to be surveyed to find the one you wanted.  In the early days of spinal CT, many films had to be viewed on each patient.

I did not forget my positive experiences as a resident when I became an attending physician.  All the images I ordered on my patients had to be seen.  I would still go down and pull the films and where necessary review them with the radiologist.  Now I had neuroradiologists to work with and they were excellent.  The medium was changing.  Eventually all of the films went away and when I went down to radiology, the reading room was still there, but now it was a computer terminal with two monitors.  The images could be immediately manipulated to show the best view.  It was no longer necessary to pull the film off the cassette and illuminate it with a bright light.  I could always ask them questions, but as time went by they were under a greater time crunch.  Now all of the dictated reports were available on the phone system and you were encouraged to listen to all of the reports.  Asking to review a series of films without listening to that report was frowned upon.  At one point in time we were all members of the same clinic, but soon all of the radiologists were spun off into a different company.  They were the same people,  just no longer affiliated with our clinic.  By  that time managed care was trying to get everyone on a productivity scale and radiology seemed like an ideal speciality to crank up the productivity expectations.

In addition to the direct experience with radiologists, the author here also seems to not recognize the value of a human brain as a processor.  I teach neurobiology to students, residents, and physicians.  Part of the job of any lecturer is to help people stay awake.  Just before I delve into the frontal cortex and its connections to the ventral striatum, I put up a slide with a fact from one of my IEEE journals:

"Equivalent computing power (depends on the simulation) using today's hardware may require up to 1.5 gigawatts to power and that is equivalent to 0.1% of the US power grid or the output of a small nuclear power plant..."   IEEE Spectrum 2012

I ask the students to speculate on how the human brain has such a tremendous amount of processing power and how it is different from computers.  Even though the audience is generally tech savvy young physicians or students, I have never heard the correct answer.  One of the correct answers is the fact that the human brain is an unparalleled pattern matching device.  There are papers where it has been estimated we can each recognize about 80,000 unique patterns.  I start to go down the list and end with studies of radiologists, dermatologists and ophthalmologists demonstrating superior pattern matching and pattern completion skill.  But I also point out, it is why that you can't learn medicine from a textbook.  It is why you need clinical exposure before you can safely practice.   You need to acquire those skills.  To my knowledge, there have been no good papers written on available pattern matching in human diagnosticians compared with the cognitive tasks they face.  For example to be a good radiologist, how many unique patterns and variations do you need to be able to see - 10,000, 50,000?  The answer to that question is critical and yet we do not know the answer for radiology or any other medical specialty.  If the number if less than 80,000 (and we don't really know this confidence interval) - Watson may have the speed but not necessarily the accuracy.  Will Watson be analogous to the current ECG computer - a general normal/abnormal reading, a reading on measurable dimensions, and then not much on equivocal cases?  Only time will tell.

So I think this Health Care Blog post has the valuable lessons of most of their posts.  I don't know the author, but it is clear that he has not worked with radiologists as long as I have.  Not just the consultations backlit by reading boxes, but the telephone conversations about the best possible test to use to investigate the problem.  If he had worked with radiologists he would know that they have always been connected throughout the careers of most physicians.  The only obstacle to that connection has been corporate medicine.  The author's seemingly friendly advice is disingenuous.  If the business administrators who run health care really wanted radiologists connecting - they would get reasonable productivity compensation for that activity.  They would not need to connect and then run back to their terminal and read enough films to make up for the period of time they were in a conference or informally teaching residents from other specialities.  I think that the admonition to connect probably means to connect with the business administrators running the health plans.  Come back into the herd and let us tell you how many images to read, just like we tell other physicians how many patients they have to see.  Advising physicians on how to behave is also a well known strategy to manipulate them.

The real message is come back to the herd or be replaced, because there is nothing that would make an administrator's day more than replacing physicians with machines - especially physicians that they have no direct control over.

IBM knows that and I know that........

An equally important question is why Watson can't replace business administrators?  They seem to have the requisite lack of technical expertise and creativity.  They need a very basic level of pattern matching to do the job, certainly no training in it.  It would seem that a very basic program to optimize the working environment for physicians, health care workers and patients would be more ideal than dabbling in an area where real expertise and collegiality is required.  I can only conclude those concepts are alien to the ever expanding group of administrators whose reason for existence seems to be managing people - whether they need it or not.


George Dawson, MD, DFAPA


Supplementary:  Although I could not work it into the above post another insidious effect of corporations on medicine has been taking teaching out of the loop.  Radiology teaching files and teaching rounds were always a rich source of learning for students and residents.  It is a required skill on most board exams.  I recall approaching an administrator about preparing teaching slides for the residency in-training exam.  It is quite easy to copy de-identified images onto PowerPoint slides for review and these images routinely appear in all major medical journals.  I will never forget the response:

"Dr. Dawson - why would we want our images to appear on teaching slides?"

Just another sign of the apocalypse.










      

"The land of 10,000 90862s"

The title of this post is an inside joke for psychiatrists.  90862 is the billing code associated with a psychiatric visit that is commonly referred to as the "med check."  It is an example of what can happen to a profession when government bureaucrats and businesses run amok in determining what they think you do or what you should be doing when you provide patient care.

I first became aware of the political importance of this system in the 1990s, when I had to attend mandatory billing and coding seminars at my place of employment.   In those seminars I learned that the politicians and insurance companies were so desperate to use this arbitrary system that they told us we could go to federal prison for a long time if we submitted a "fraudulent" billing document.  The "fraudulent" document they were talking about was any bill connected to the document of a patient encounter that did not have enough bullet points to qualify for that level of billing.

That is an important concept so let me say it another way.  After every patient encounter, the physician needs to document a note about what happened and indicate a level of billing for that encounter.  When I first started training the note could be as little as one or two lines.  For example, at one point in my training I covered an entire surgical service with a team of doctors.  We could round on 25-30 patients with very complicated problems and write all of the documentation in about 2 hours.  The documentation was "Pain is well controlled, surgical site looks good, vital signs are stable."  We did not have to bother with any billing documents because a hospital billing specialist came by and confirmed that we had seen the patient and submitted the bill.

Somewhere  in the 1990s, a government initiative changed all of that.  The government decided that they needed a way to control the global budget for physician salaries and they decided to develop a system of codes for patient encounters that they assign relative values to and then multiply that by a certain number to set reimbursement for that code.  The entire system rests on the assumption that somebody can look at the description of a patient encounter as written in a note and audit the associated billing document.  It turns out that when this assumption was tested several years later - it was determined to be false, but that did not deter the federal government or the health insurance industry (see reference).

The 90862 is probably the most abused billing code in the psychiatric profession.  The interpretation of what constitutes an encounter that qualifies for this code varies from practice to practice and between organizations.  Patient experience varies from literally talking to a psychiatrist for 5 minutes with the goal of getting a prescription refill to a much richer encounter that includes a discussion of other current problems, additional medical diagnostic discussions and psychological advice.  In some cases, acute medical problems requiring emergency care have been identified in these sessions.  There is no doubt that a considerable amount of gaming occurs on the part of some clinicians and most insurance companies and government payers.

The only gaming possible by the clinician occurs at two levels.  The first is total time spent with the patient.  The folklore is that these are all 15 minute encounters.  Some clinicians insist on seeing patients in half hour blocks and others see 3 - 4 people per hour.  The second is total documentation.  You can literally do a few lines or you can write several paragraphs and stay after work just to do the documentation.  A lot depends on whether you think you will be audited and somebody will be making an arbitrary decision about whether your note qualifies for the charge that you assign to it.

There are myriad ways that a managed care company can game the system.  First of all, they can assign any level of reimbursement to any billing code that they want.  I quoted a New York Times article in another post as saying that a psychiatrist could see three patients for medications and get reimbursed at $50 per session, but the actual reimbursement can be less than half of that.  That same managed care company can also take any bills submitted for patient encounters with higher reimbursement levels and say: "we are only paying you for a 90862 no matter what you do."  If you happen to be working in an institutional setting, a managed care company can negotiate a per diem rate with your employer and not pay the 90862 billing at all.

Stated another way, a psychiatrist can see a patient with complex medical and psychiatric problems and get reimbursed at a level that might lead to them break even - to getting no reimbursement at all depending on the insurance company and contracting arrangements.  Within organizations the relative values for these codes are the basic way that physicians are manipulated to see more patients.  It is referred to as their "productivity" even though producing work for little or no reimbursement is not really productive activity.  The physician managers can demand that they see more and more patients to compensate for the poor or nonexistent rate of reimbursement by managed care companies.

Another artifact of this system is that procedures like surgeries, endoscopies, and angioplasties are reimbursed at a higher rates than a doctor talking with you and discussing the diagnosis and treatment.  That lead to a movement to reimburse the cognitive or nonproceduralist specialties at higher rates.  But given the amount of government payer and insurance company leverage it is impossible to make that happen.

Is there a solution to this problem that in effect makes physicians work impossibly harder to earn a professional salary?  The solution is as easy as considering how I pay my attorney, accountant, mechanic, plumber, electrician, and chimney sweep.  I pay them all by the hour.  In some cases there is an agreed fixed amount, but it is generally many times more than what I would get reimbursed for the lowest 90862 reimbursement.

Getting back to the title of this post, when I looked at the lowest current reimbursement for a 90862 and calculated how many of those bills would need to be submitted to make a professional wage, it came out to about 10,000 patient encounters per year.  Working 50 weeks per year that would mean seeing 40 established patients per day.  The only clinic where I have ever observed those numbers had three nurses rooming the patients and doing all of the documentation before they were briefly seen by a psychiatrist.

As I contemplated all of this I had the thought: "I am living in the 'Land of 10,000 lakes' - maybe we should just change that to the 'Land of 10,000 90862s.' "

George Dawson, MD

King MS, Lipsky MS, Sharp L. Expert agreement in Current Procedural Terminology evaluation and management coding. Arch Intern Med. 2002 Feb 11;162(3):316-20.

90862 Redux? An Update.

Financial Marginalization of Psychiatry

I wrote this original article in 2005 for the Minnesota Psychiatric Society newsletter in response to two developments.  First, it is one of the only articles that you will ever see quoting actual prices in terms of bills and what the actual reimbursement is.  Contrary to the myth of expensive health care, I have had people tell me how shocked they were at how little of a bill the insurance company actually paid.  The author here gives the actual dollar amounts.  Second, there is an obvious boom in Cardiology services at a time when psychiatric services were being strictly rationed according to managed care "carve out techniques." At the  time this article was originally written 100,000 patients per year received implantable cardioverter devices (ICDs) at a cost of $2 billion and a pulse generator replacement cost of an additional $1.4 billion.  Using the figures from this article that is the equivalent of 794,000 psychiatric hospitalizations per year.  The original article and the reference begins with the paragraph below.

A recent Twin Cities article on the escalation of technology and real costs for cardiac care in Minnesota highlighted just how severe the resources have been skewed away from psychiatric care. If you have been following the Minnesota Psychiatric Society's initiatives in this area over the past few years it will probably come as no surprise - but even in that context I found the following numbers somewhat shocking:

1. Minnesota (a state with maximal managed care penetration) - has 40% fewer mental health beds per capita than the nation.

2. In the past 5 years - 5 new cardiac care facilities have opened at a cost of $263 million.

3. An analysis of Medicare cost data for one hospital (United) shows why cardiac care is expanding and psychiatric care is shrinking. Here is a direct quote from the article:

"A look at Medicare cost data for one local hospital shows why. It cost United Hospital $8,091 to implant a pacemaker, but the hospital received $11, 538 for each procedure, according to 2003 data provided by the American Hospital Directory.

On the other hand, it cost United $10, 132 to treat a patient with psychosis, but the hospital received only $4, 282 per case. These are federal Medicare figures but the same disparities exist in payments by private health plans."

That's why you are seeing all of those shiny new Heart centers and no new psychiatric hospitals. Combined with the psychiatric outpatient penalty - it probably also goes a way toward explaining why the system is so fragmented and the seriously ill cannot find a psychiatrist.  Also notice that the insurers were described as worried about how to contain Cardiology costs, but the reality here is that all of these Cardiology services are owned by the major managed care companies.

George Dawson, MD

Hauser RG.  The growing mismatch between patient longevity and the service life of implantable cardioverter-defibrillators.  Journal of American College of Cardiology 2005; 45 2022-5.

Olson J. Cardiac care focus worries insurers. Pioneer Press, August 8, 2005: p 1A, 4A

Knowledge Workers

Imagine working in an environment that is optimized for physicians. There are no obstacles to providing care for your patients. You receive adequate decision-support. Your work is valued and you are part of the team that gets you immediate support if you encounter problems outside of your expertise.  In the optimized environment you feel that you are working at a level consistent with your training and current capacity. That environment allows you to focus on your diagnosis and treatment of the patient with minimal time needed for documentation and coding and no time wasted responding to insurance companies and pharmacy benefit managers.

As I think about the problems we all encounter in our work environment on a daily basis I had the recent  thought that this is really a management problem.  Most of the management that physicians encounter is strictly focused on their so-called productivity.  That in turn is based on an RVU system that really has no research evidence and is clearly a political instrument used to adjust the global budget for physicians.   Current state-of-the-art management for physicians generally involves a manager telling them that they need to generate more RVUs every year.  Managers will also generally design benefits and salary packages that are competitive in order to reduce physician loss, but this is always in the larger context of increasing RVU productivity.   Internet searches on the subject of physician management generally bring back diverse topics like "problem doctors", “managing physician performance”, "disruptive behavior", “anger management”, and “alcoholism”, but nothing about a management plan that would be mutually beneficial for physicians, their patients and the businesses they work for.

In my research about employee management I encountered the work of the late Peter Drucker in the Harvard Business Review.  Drucker was widely recognized as a management guru with insights into how to manage personnel and information going into the 21st century. One of his key concepts was that of the "knowledge worker".   He discussed the evolution of managing workers from a time where the manager had typically worked all the jobs he was supervising and work output was more typically measured in quantity rather than quality. By contrast knowledge workers will generally know much more about their work than the manager.   Work quality is more characteristic than quantity.   Knowledge workers typically are the major asset of the corporation and attracting and retaining them is a corporate goal.   Physicians are clearly knowledge workers but they are currently being managed like production workers.

The mistakes made in managing physicians in general and psychiatrists in particular are too numerous to outline in this essay. The current payers and companies managing physicians have erected barriers to their physician-knowledge workers rather than optimizing their work environments. The end result has been an environment that actually restricts access to the most highly trained knowledge workers.   It does not take an expert in management to realize that this is not an efficient way to run a knowledge based business.   Would you restrict access to engineers and architects who are working on projects that could be best accomplished by those disciplines?   Would you replace the engineers and architects by general contractors or laborers?   I see this dynamic occurring constantly across clinical settings in Minnesota and it applies to any model that reduces psychiatric care to prescribing a limited formulary of drugs.

I think that there are basically three solutions.   The first is a partial but necessary step and that is telling everyone we know that we have been mismanaged and this is a real source of the so-called shortage of psychiatrists.  The second approach is addressing the issue of RVU based pay directly.   I will address the commonly used 90862 or medication management code.  As far as I can tell people completing this code generally fill out a limited template of information, ask about medication side effects, and record the patient's description of where they are in the longitudinal course of their symptoms and side effects.  Many managed care companies will ONLY reimburse psychiatrists for this stripped down intervention.    I would suggest that adding an AIMS evaluation or screen for metabolic syndrome, an in-depth probe into their current nonpsychiatric medications and how they interact with their current therapy, adding a brief psychotherapeutic intervention, case management discussions with other providers or family, and certainly any new acute medical or psychiatric problems addressed are all à la cart items that need to be assigned RVU status and added to the basic code.   Although there are more, these are just a few areas where psychiatrists add quality care to the prescription of medicines and managed care companies do not.  The final solution looks ahead to the future and the psychiatrist role in the medical home approach to integrated care. We currently have to decide where we fit in that model and make sure that we don't end up getting paid on an RVU basis while we are providing hours of consultation to primary care physicians every day.

Overall these are political problems at the legislative, bureaucratic and business levels.  It should be apparent to anyone in practice that when political pressure succeeds in dumbing down your profession – it necessarily impacts adversely on your work environment, compensation, and most importantly your ability to deliver quality care.