Virtual House Party held by Association of American Physicians and Surgeons by telephone conference , Dec. 16, 2008
Purpose of the house parties:
Arizona internist: Looking at the agendas that the Transition Team distributed, it appears me that they are looking for what I would call Klagenlieder (complaint songs, lamentations): anecdotes about how awful it is to be sick and how physicians failed to solve the problem, and how the government has to ride to their rescue.
New York anesthesiologist (also a consultant in forensic science): Right. These seem to be preordained, scripted situations where they�re looking for tear-jerkers. Although it makes some copy, all told I�m not sure that would necessarily carry the day. Especially when people who themselves have issues that were addressed and addressed well will come out of the woodwork and say, �I don�t want to be in a situation where I can�t pick someone who can diagnose my problem.�
The process:
AAPS legal counsel:
Apparently what they�re doing this time is the meetings are being held with the insurance industry and other stakeholders out of Kennedy�s office and with his staff. That bypasses a lot of accountability that we had last time when Hillary Clinton was having these meetings with industry and so on out of the executive branch. When the legislative branch has these meetings they�re not subject to FOIA [the Freedom of Information Act] and they�re not subject to FACA [the Federal Advisory Committee Act]. It�s very difficult to get the transparency that we need to see what kind of deals are being cut and who�s going to get the goodies and so on.
One of the goodies they�re thinking about handing out is mandatory insurance. To get the insurance industry�s full support they�re thinking about requiring everybody to buy insurance. That sure would be a nice benefit to someone who�s in the business of selling insurance. It can be pretty costly and it can force people into plans that they don�t want.
I guess the biggest concern here of all is they�re not telling us. The legislatures are not telling dir>through Congress with very little transparency.
We think a lot of the details are going to be delegated to Tom Daschle, Secretary-designate of HHS, where there will be absolutely no democratic input into it because that�s an administrative agency. Daschle�s not going to be accountable to anybody. He�ll just write the regulations and put them out there.
Then people may be standing in line for doctors as is happening in Massachusetts right now. In some areas of Massachusetts you can�t get an appointment with a doctor for a physical for more than a year. Then people start flooding the emergency room with conditions that could be handled much more efficiently with a doctor�s visit. The doctors� offices are all clogged up with people who are forced to buy insurance and didn�t really need to see a doctor.
Underlying presumptions: the number of uninsured:
Retired California OB/gyn: The Urban Institute did a study on the claimed 45 million uninsured and found that it included 14 million housewives covered by their husbands; 2 million to 4 million college students covered by the families; and apparently 10 million actually covered by Medicaid. The real number may be 9 million to 15 million. But the AMA recently used the45 million number, apparently in an effort to convince the public that the current system is broken and cannot be saved, and that it needs to be replaced. It�s as though you have a Cadillac and you�re going to throw it out because it has a flat tire. Rather than fix it they want to replace it.
Practice guidelines, pay for performance, medical errors
New York anesthesiologist: First, the general nature of medicine is that it�s an inefficient undertaking if you do it right. You can�t exam people or question them in a highly efficient manner without neglecting certain things. To make this profession efficient and pathway dependent will remove all stimulus to advancement and innovation. However helpful to patients, innovation will be disruptive to the approved pathway, which will have the force of law. Or at a minimum the threat of a lawsuit or the economic disincentive of noncovered status will deter innovation. We�re in danger of losing, as both physicians and patients, the freedom to contract with whom we wish, for the treatment that we prefer.
New York neurologist: I have personal experience these past couple of years with practice guidelines, after reading about them. They are enforced by hospital administrators and nurses. It would be one thing for the practice guidelines to be reviewed by jury of peers, say for neurological guidelines, and compliance with same to be reviewed by a neurologist. It�s another to be made and reviewed nurses. As has been said in the AAPS journal, the practice guidelines don�t emphasize the diagnosis. People can be congratulating themselves for following the guidelines and doing a great job, when they have started out with the wrong diagnosis! For example, I have seen the results of nurse practitioners seeing patients for back pain�although the patient is paying to see a doctor. The nurse did not examine the patient properly and find that his reflexes were increased, not decreased, signifying a spinal cord problem. I�ve seen that commonly, every few months now. The nurse may get credit for following guidelines�while missing cervical or thoracic spinal cord pathology, or even cerebral pathology.
I recently was visiting my mother, who had been my office manager for 21 years, in the nursing home. She had a partial complex seizure. I found myself being bossed around by a GPN (Graduate Practical Nurse?). For this degree, she needed 79 hours of training. She was giving me orders that I shouldn�t be checking for neck rigidity if I thought the patient might have had a seizure! Nursing homes have rules designed to protect their personnel that are being used in ways that threaten the health of nursing home residents. How many people in nursing homes all over the country are having seizures and just being ignored until they die in bed, and are said to have died of old age?
In one hospital, a patient had a broken neck that everyone missed. The patient refused a CT scan, and nobody called to tell me that. In the old days, nurses were taught to call the doctor in the middle of the night when the patient refused a test that might be critical for making a diagnosis. They did, however, make sure the patient�s flu shots were up to date! For all the �quality assurance� and guidelines, the quality of care is not what we used to have. Instead of making the right diagnosis, everybody in the hospital is focused on making sure that all the patients have all their shots!
West Virginia pulmonologist:The problem as I see it is the push now will be for more government control, more government programs, more central control. Those programs are the same ones that aren�t working now. The gadgets they�re using to try to tweak them to make them better aren�t going to work either. With things like pay for performance, you need to look at the outcome of what you�re proposing, and nobody�s doing that I don�t think.
The whole idea of practice guidelines and evidence-based medicine was effectively discredited by a recent interesting article by Martin Tobin from Loyola University School of Medicine in the Journal Chest. These ideas have never been validated nor have them been shown to work. [In other words, evidence-based medicine is not evidence based!]
Texas anesthesiologist/pain specialist: I really believe it is a huge mistake to base our future on �evidence-based medicine.� Insurance companies try to pigeon hole patients into diagnostic categories of borderline relevance. Attempts to apply the results of available clinical trials are likely to treat patients inappropriately, as well as to discourage independent thought and innovation.
Information technology and the electronic medical record (EMR):
New York anesthesiologist: Any kind of gain that could be had from forced centralization and collection of personal medical data would be offset by the loss of patient confidentiality. The notion that data would be secure, and remain so indefinitely, is really illusory. Even if severe penalties were meted out to those who breached the system, accessed someone�s information, and disseminated or used it�and even if the guilty person could be caught and successfully prosecuted, what good does it do for the person whose privacy was lost? The damage can never, ever be undone. If we are really intent on having some kind of computerization, the cheapest way would be to buy everybody a $5 thumb drive. People could make their own decisions about giving their data to practitioners or regulators.
Texas administrator (who has MBA in information technology): I�d like to second that. I believe that there is an obsession with information technology as being the saving factor for the medical industry, and it is completely erroneous. Misdiagnosis or error in inputting a treatment plan can cause havoc.
I think that instead of spending the billions we�re contemplating, the idea of a portable transfer device for personalized information is brilliant and much more cost-effective.
California hospitalist: First off, as a hospitalist I can tell you that I do believe that there does need to be an investment in information technology. Unfunded mandates such as the electronic prescribing and electronic health records, while they�re good ideas at their core, they�re costly and poorly integrated. They won�t even talk to each other right now. Many EMRs (electronic medical records) result in doctors spending more time typing into a computer than actually talking to the patient.
Some seem to think that the EMR is the salvation of medicine. Well it�s not. It�s just a tool to make our job easier and supposedly to make our decisions more informed. While these are tools that we can use there�s no substitute for the accumulated education and experience that a doctor can bring to bear on an ailment. To minimize the role of physicians is playing into the hands of the insurance oligopoly and Medicare bureaucrats that have us believe that all of our medical ills can be handled by a physician assistant or nurse practitioner with the aid of a computer. That�s just idiocy. We deserve to get what we pay for them. What we really need is to reimburse the cognitive specialties adequately so a doctor can spend the time it takes to get a full history, do a full physical exam, and sit with the patient and explain the most likely diagnosis, to do the research and lay out a rational course for diagnostic testing and treatment. Instead what we get is 11-minute exams. I believe that many doctors do the shotgun approach simply because they cannot take the time to clinically tease out what the most likely problem is and explain to the patient what�s going on.
Question from unidentified speaker: Do other people find reading electronic medical records just horrendous, or is it just me?
New York neurologist (?): It depends on how it was implemented, but most of the time you�re right. It�s just reading the same stuff over and over and over again. They don�t even bother to bold the one or two lines that were new.
Ohio plastic surgeon: It�s absolutely horrible. A lot of the problem is that the information isn�t entered in a timely way. The doctors who are making rounds find it is very time-consuming to enter the data, so they do it all at once, maybe several hours later. Sometimes the information never gets entered at all, or isn�t as precise as it needs to be because it takes so long to enter. It�s horrible.
New York neurologist (?): I think that were electronic medical records implemented in a correct way that with a lot of input from doctors they could potentially save lives. If you knew that the patient had gotten a certain treatment in some other state and knew that they did poorly with, say Neurontin, and you�re trying Lyrica on them now. There�s so many times that I can�t get records at 2:00 in the morning. A lot of times those records could potentially have changed what I did with a patient. If there were an electronic medical record system that could be accessed so that I knew what I was doing it would be helpful.
Ohio plastic surgeon: No, I don�t think so. The patient will tell you what�s working and what isn�t. You don�t need an EMR for that. Just ask the patient. There�s no way the EMR will be effective and cost effective as well. It�s a waste of time. It�s a waste of money. It�s nonsense. It needs to be stopped.
A hospital where I do a lot of surgery has just spent $78 million on a computer system that I call a complete failure. This system does not allow one to make certain choices about where you want to enter data. Sometimes the computer technician, or the one who is designated to help you doesn�t know how to enter the data either. It�s disastrous. I don�t think it�s effective. I think computers are great for some things but they�re certainly not great for going completely paperless like this hospital has gone. Furthermore, $78 million can be spent in a lot better way, I think, than on a computer system. Yet all of the other hospitals in town are wanting to go this direction too. It�s virtually impossible to talk them out of it despite the huge expense, which I think is going to be a complete waste of money.
Texas administrator: I�d like to comment as a nonphysician but as an IT (information technology) specialist. One of the concerns that I have is when you�re preparing a routine and a sub routine to run a program. I think that one of the issues is the medical criteria that some programmer in New Delhi will use and that you physicians are eventually going to be held accountable for. That is one major, major concern. The program is not going to be prepared by one company in one location. It�s going too outsourced right and left, using the cheapest source. It�s not just the cost you�re going to have to deal with, but the garbage that will be on your screen. You�ll be going through medical school to wind up being a data entry clerk.
Arizona internist: There�s also the possibility that you data you see is from some other patient, given the problems with medical identity theft.
Texas administrator: It�s very easy to have errors, especially with information bouncing around in a closed-network environment such as the hospital. It can also get lost or deleted. It�s not a good idea to move so quickly in this area. While IT is inevitable, it needs to come slowly, one step at a time.
Monopolistic control of medicine:
Texas administrator: I�m afraid that what we�re looking at is the elimination of private physician as a private entrepreneur and businessman. Although reformers are conscious of the monopolistic restraint of trade that we�re dealing with, they nonetheless want to give control to third-party payers who have a stranglehold on the system. They want to make it completely impossible to escape from this situation.
Ohio plastic surgeon: I�m one of those millions of uninsured people, by choice. So are the three other people who live in my house. We choose to be uninsured because we have freedom to choose. An OB/gyn specialist whom I helped with a small problem told me all the errors that managed care companies have made over the past few years, and their demands on OB/gyn doctors. My family does not want to be part of that. We want to choose our own medical treatment and not be forced into an insurance arrangement that we do not like.
We�re seeing more and more monopolization of the insurance companies. The big insurance companies get all of the breaks from the hospitals. One medical savings insurance company out of Indiana is just now going out of business because they can�t compete. The hospitals have been unfair with them.
The answer to the many problems that I need to be solved is not to do more of the same but to go back to a free-market system where you have fewer big players and more entrepreneurs and more and smaller insurance companies, which don�t have a monopoly.
Louisiana internist and emergency physician: I�m also uninsured by choice and happy to be paying one-fifth the average amount spent in the U.S. on medical care. I also share the concerns about the monopolistic empires being built.
Another problem that I believe is not receiving enough attention is the impact of medical malpractice laws and of the National Practitioner Data Bank. Primary physicians are reduced to checking boxes; physicians� fees constitute about 20 cents of the medical dollar; and the system is dominated by lying, less educated lawyers. The people who are making the laws unfortunately in many cases have a vested interest and may be in the back pockets of those who want to build a bigger information empire, bigger x-ray empire, bigger lab empire.
Illinois pathologist: We tend to think that government is in competition with big business. Actually, doctors are in competition with both of them. On the one hand, we have zealous over egulators and on the other hand we have big corporations swallowing up our practices, violating court orders to make horrific decisions. My one suggestion is this: �Government, get out of bed with the big corporations that are trying to choke us to death.�
Texas administrator: Another problem with insurance companies that we�ve seen in Texas is with the insurer practically buying its way into the medical board. The increased power they will have with everybody being forced to buy insurance will be a catastrophe that many physicians aren�t aware of because not all medical boards are as atrocious and as abusive as the Texas board has been. If insurers get increased power and money, the Texas Medical Board will become the norm for the country. That�s one of the things I am most afraid of. Medical malpractice will also be a tool for the insurance companies to shut up the physicians who are more concern with their patients than they are about compliance with payment laws.
Universal coverage and primary care:
California hospitalist: Everybody in our current leadership is just missing the point. They�re talking about insuring everybody, yet the Massachusetts experience has shown that you can insure (almost) everybody, but if you don�t have any primary-care doctors to see them it�s a currency without a marketplace.
Primary care medicine right now is dead. Without prompt resuscitative efforts the patient is going to suffer brain death. This is not a time for band aids, it�s not a time for oral amoxicillin, it�s time for intracardiac epinephrine and counter shock before it�s too late.
I believe most doctors are very hard working and dedicated. I know there are many critics who don�t think so. Can you think of any other business though in which I�d be paid the same if I�m called in at 2:00 a.m. on a holiday as at 2:00 p.m. on a working day? We�re paid nothing for email or other communications with the patient. We�re paid nothing for many of the things that we do and that take time and effort. Can you imagine a lawyer getting paid nothing for any of those things? Primary care practices are going out of business in record numbers because of the economic constraints, and no one�s going to replace them. I was a primary care doctor until November 2007, when I closed my primary care practice for the final time after making only $30,000 in my last year. I�d be glad to show my W-2 form. When I left primary care, my patients were very concerned about how little money I was making, and about the death of primary care.
Arizona internist: What kind of resuscitative efforts for primary care would you suggest?
California, hospitalist, continued: In my humble opinion, number one, if you�re going to try and tweak the current system, which I actually don�t believe in, you need to at least triple and I�m not kidding, triple reimbursement for primary-care doctors. Actually, I disbelieve in the whole idea of insurance companies running medicine because that�s what they�re doing right now. They�re making medical decisions without any kind of oversight or accountability for when things go wrong. But I believe that HMOs did work in one way: They did they made patients believe that office visits should be $10. That�s what my office visits are worth to them.
What we need is more medical savings accounts. Health insurance should be like auto insurance. Does your auto insurance pay for your oil, your gasoline, your tires? Let�s make one that does. So for a $5 co-pay you get a tank of gas, for a $10 co-pay you get tires, and for a $50 co-pay you get body work. I don�t need to tell you that people will drive their car more often. When they get that ding in the parking lot they�re going to get it repaired because it only cost them $50. The fact is that the cost in this system would ramp up so quickly the insurance companies would be forced to raise rates until they are at least 300% of what they currently are. Then people wouldn�t be able to afford them, and there would be lots of uninsured drivers. That policy would be like what we have right now for health insurance. So why is auto insurance so much cheaper? The answer is that your auto insurance doesn�t pay for your gas, doesn�t pay for your tires, doesn�t pay for you day-to-day expenses. It only pays for catastrophic losses. Moreover, the premium is based on risk.
Texas anesthesiologist/pain specialist: I�ll echo the need to pay primary doctors better, but we need to pay all the doctors adequately. We�ve all seen a drop in our reimbursement over the last 20 years, and even over the last five years. I tell you we�ve all seen at least 50% drops in our reimbursement. We are all working harder. Patients are complaining because they don�t see their doctor; they see a PA. Well the doctor simply can�t afford to see the patient every time. Not now, not with the terrible reimbursement and the costs of keeping an office open.
One way to cut some cost would be to take a lot of the fat out of the system, but I see no prospect of that happening with a socialized medicine system. Pay the people who actually practice medicine, who actually do things for patients, as opposed to administrators and the prostitutes that work for the insurance companies that keep the rest of us from doing what we�re trained to do, such as practicing medicine.
West Virginia pulmonologist: The history is that all these schemes for universal coverage have been tried, and have failed. They failed in Hawaii. They are failing in Massachusetts.
Arizona internist: Massachusetts has been getting a lot of good press. The public support is said to be great. But they leave out the little fact that the people who are most affected by the plans are actually opposed to it.
Reducing costs:
Texas anesthesiologist/pain specialist (?): One thing I haven�t heard the Transition Team comment on is the enormous cost of defensive medicine. Then there�s the cost of the paperwork requirements. It certainly would simplify our lives if, instead of having to document a bunch of meaningless trivia to get paid for 99214 or 99213 office visit, we could just say we spent 15 or 20 minutes with the patient.
New York neurologist: According to an article in Neurology Today, the Massachusetts plan is projected to reach 342,000 people and $1.3 billion of annual expenses by June 2011. That�s a huge increase over the original expectations. The state officials underestimated the number of uninsured residents. Even the doctors say there�s nothing in the plan that constrains cost. Premiums continue to rise at twice the rate of inflation. There�s 4% surcharge on each policy.
Texas administrator: In order for me to make more money as an insurance administrator I am going to be more prone to push to use PAs and nurse practitioners and give them much more leeway under the guise of access to health care.
Arizona internist: What about the promise that if everybody would just get preventive interventions, sickness and costs would diminish?
Various commenters: Nonsense. People, even highly educated people don�t want to get a colonoscopy every two years. They won�t do it. Even if they did, it wouldn�t save money; the promise seems to be based on the premise that death is an option. Maybe if we paid primary-care physicians the way they should be paid, so they could see patients the way that they should be seen, we could head off some very expensive illnesses.
Arizona internist: Would the medical home accomplish that?
Various commenters: Not the way it will be implemented, as a typical unfunded government mandate. Many big systems have already attempted the medical home. They�ve spent a lot of money on it. And they�re all losing money on it. If they�re going to lose money on it then what hope do I have as a primary-care doctor in the middle of nowhere?
Arizona internist: Are there better medical outcomes elsewhere?
Various commenters: The United States is still far and above all of the other countries in cardiac and cancer care. The infant mortality statistics somehow ignore all the crack babies and low-birth-weight babies that aren�t counted as live births elsewhere. There are endless anecdotes about horrible care in socialized countries.
California OB/gyn: The press doesn�t tell you that because it wants government medicine. It doesn�t tell people about the patient with a brain tumor who couldn�t get care in Canada for 6 months, but came to America and was taken care of immediately. That�s what people need to know about.
Illinois pathologist: The Hippocratic Oath is really it�s a joke because we can�t comply with it any more. What I tell my people on my website that has 1.8 million visits is that if somebody tells you to violate your principles, even the government, they have to be resisted with contempt.
Commenter: But then you�re a �disruptive physician,� and soon you won�t be permitted to be a physician any more.
Arizona internist: That brings us to the end of our conference. We will circulate an edited transcript, and others may wish to comment also.
