Monday, February 20, 2012


Goldilocks went to Forest Medical Center to look for healthcare.
First she came upon Managed Care.  She said “This kind of care is too small.”
Managed Care means there is an advantage to providing only the care that must be provided and nothing more.  In the abstract, it makes sense.  Why would you want procedure and tests done that aren’t necessary.  The rub is who decides what is necessary care? Who decides?
Usually Managed Care means an HMO.  The physicians in the HMO are rewarded financially for NOT spending healthcare dollars.   They have a regularly scheduled meeting, get a pat on the back, and hopefully a check.
Another scenario where there is an incentive to do less is Academic Medicine.  Physicians who teach residents and are paid by a university usually do not make more money if they see more patients or do more procedures.  They are paid the same salary regardless of the workload.  Doing more procedures does not net them more money, it just creates more work.
The full extent of “less is more” is seen in residency.  What resident hasn’t stormed down to the Emergency Room to dispute an admission to the hospital?  Discharge planning starts on hospital admission as a matter of survival.  More patients on your service = less sleep for you.

Let’s take an example of a patient with Congestive Heart Failure (CHF).  Severe CHF causes frequent hospitalizations.  Let’s say our patient, Mr. Bear, gets admitted to the hospital for CHF.  He receives the usual care and is discharged 2 days later.  The hospital gets paid based on what is called a DRG (Diagnosis Related Group).  If he stays 2 days or 2 weeks, the hospital gets paid the same.  The hospital has an incentive to get Mr. Bear out of the hospital as quickly as possible.    If the hospital tries to create a financial incentive for the doctor to make this hospital stay shorter, it violates the Stark Law.  The Stark Law is there to protect the patient’s interest.  It is to keep financial interest from interfering with good patient care.  Unfortunately, it can have unintended consequences.

Second she came upon Fee-For-Service.  “This kind of care is too large”, said Goldilocks.
Fee-For-Service refers to getting paid for things you do.  This means the more patients you see, the more procedures you perform, the more you make.  In this scenario, “more is more”.  There is a financial incentive to do more, whether or not the patient needs it.  I’m not saying that doctors will always intentionally do unnecessary procedures just to make a buck.  I am saying that financial incentives can cloud decision-making.  The Stark Law is also intended to protect the patient in this example.  If Dr. BB Wolf orders a test to be done at the B.B.WOLF Diagnostic Center, and Dr. Wolf makes money from tests done at his center, he must inform his patient that he could also have the testing done at the L.R. RIDINGHOOD Diagnostic Center.  If he doesn’t inform him of his options in writing, he violates Stark Law.
Let’s get back to Mr. Bear.  Dr. B.B. Wolf discovers that Mr. Bear has iron-deficiency anemia and a small lung nodule.  The doctor does not have a financial incentive to get Mr. Bear out of the hospital as quickly as possible.  He does have an incentive to address his problems now.  He get consults for Mr. Bear’s iron deficiency and small lung nodule, both things which could happen as an out-patient.  This may give more work to Dr. Wolf and his specialist friends.  With the current system, there is no incentive NOT to do this.  Also, this insures the workup is done so that Dr. Wolf isn’t sued when Mr. Bear doesn’t follow up.

Finally Goldilocks came to Accountable Care.  “This kind of care is just right!”   
Accountable Care is hopefully the solution to the problems with the above care models.  The patients are considered not as a discrete visit to a hospital or office, but rather as a whole person with all medical costs taken into account.  With this model, everyone involved in the care of the patient has a reason to keep them healthy.  The more money spent on the patient, the less the doctor makes.  Does this mean deny care for the patient?  No.  It means care for the patient in a way that keeps them healthier and out of the hospital.  If they are in the hospital, get them out quickly.   More importantly, keep them from being readmitted to the hospital. 
In the example of Mr. Bear, he really doesn’t want to spend his days in the hospital.  He would rather take his grandchildren for a walk in the forest.  With an Accountable Care Organization (ACO), the hospital can create an incentive for the physician to efficiently and safely take care of his CHF and send him home.  Stark Law does not interfere in this case.  The ACO then makes sure that he understands how to manage his CHF so he doesn’t end up right back in the hospital.  A team approach and a Medical Home provide the basis for coordinated care for Mr. Bear.  His iron deficiency and lung nodule are evaluated in a reasonable way as an out-patient, at a lower cost for everyone.  He feels more in control of his health and appreciates less visits to the Emergency Room.
These issues are more complicated than Mr. Bear or Goldilocks will ever know.  There is not one easy solution.  What Accountable Care Organizations hope to achieve is better patient care with less money.  The financial incentives don’t encourage too much or not enough.  The incentive is for just the right amount of healthcare. 
I have just signed with an ACO.  It is a leap of faith, but I have always been an optimist.  I am sure there will be barriers and frustrations.  At least in theory, this type of care will be best for my patients and aligns most closely with the way I practice medicine anyway. 

Wednesday, February 15, 2012


I rented Ferris Bueller's Day Off for my girls.  They had never seen it, though they have heard us quote it on occasion.  I thought they should see it for Pop Culture Literacy.
One kiddo refused to watch because she knew there was an anxiety-provoking scene with Cameron and the Ferrari.  The other kiddo watched the whole thing and thoroughly enjoyed it.
What amazed me most is how much I enjoyed it after all of these years.  Even though I am no longer in highschool, I think we can all relate to being trapped in a classroom.  I think highschool just prepares us for all of the crappy jobs we have to endure before we hopefully find one we like. 
I hear stories all day long about abusive bosses and companies.  Gone are the days when loyalty was rewarded.  Now you are expected to skip your vacation days, work 10-12 hours a day, and if you get sick or have family issues, we'll just replace you.
We create most of the obstacles to our own happy lives.  We make things too complicated and hold fast to assumptions that leave us chained to things that don't really enrich our lives.
So, unless you have the rare boss that gives you the respect you deserve, why don't you take a Mental Health Day?  Hit the bookstore, the library, the museum.  Buy a journal and write in it.  Think about what you REALLY want out of life.  Remember, there is no finish line in life.  You will not reach a point where someone tells you to take it easy and enjoy yourself. You have to do that now. 
If you don't believe me, ask Ferris.

Friday, February 10, 2012

Why I love my Electronic Medical Record

I love hearing the "controversy" about electronic medical records (EMRs).  There has been resistance from doctors for many reasons. Just last week I read a scathing blog from a doctor about why he dislikes EMRs.  I used to feel the same way, and then...

Let me tell you the tale of my quest for an EMR and the love story that follows.

In 2008 I left a great job at MD Anderson to start my practice.  With nothing but a new Vaio laptop, a stethoscope and a line of credit, I started my business and my medical practice. 

One of my first decisions:  Paper or Plastic?  I decided to get an EMR if I could in any way afford it.  I don't like killing trees, I like being able to access my records from anywhere I can access the internet, and since I had a tabula rasa, I didn't have to worry about converting charts to a new system.

My second decision: which EMR?  I had no cash flow since it takes months to get contracted with insurance companies.  I was doing hospice house calls to pay the bills.  I started a process of reviewing all of the major players.  I looked in vain for pricing on the internet.  I tried to get prices from the vendors.  All of them required an online/phone meeting first so they could show me all of the bells and whistles.  All of them would then drop the bomb about price.  I would try no to gasp or laugh.  They all wanted thousands if not tens of thousands of dollars for the system, PLUS I had to close my office for a week to train my staff, PLUS I had to pay their peeps several hundred dollars a day for the training (with no option for less days of training or no training), PLUS a monthly service fee.  My favorite was the vendor that wanted me to pay for their staff to fly to Houston, put them up in a hotel and feed them, on top of the several hundred dollars a day for training.  After a frustrating summer of these useless calls, I was starting to think, "Man, what have those trees every done for me?  Why not kill a few of them?"

That is when I read about Practice Fusion.  It was in the comments of an article in I believe the NYT, an article about poor adoption of EMRs by physicians.  It said it was FREE.  Well hallelujah!  Where had they been all summer? Apparently they had been there but didn't have millions to spend on advertising their product so I had not heard of them.  I got right online and was up and running by the next day.  I couldn't believe I was getting for free what so many others paid top dollar for.  Sure, it didn't have all the bells and whistles, but there were promises of future noise-making capabilities.

How do they do it?  Well, they have advertisements.  Just like most of the free stuff on the internet, they have ads.  They make their money off of advertising.  Do I have a problem with this?  Heck no!  Just like I don't have a problem with my county and state medical societies making money by selling ads to the very expensive EMR vendors.

In fact, my state medical association was hitting all of the big hospitals and county medical societies to talk about which EMR to choose.  They compared and contrasted the big 5, or what they considered to be the big 5.  I was at one of these meetings and asked why they weren't making physicians aware of the FREE EMR?  Why were they focusing on how to get financing to pay for expensive systems when you could just get a free one?  I received a vague response about only being able to review 5 EMRs.  Several doctors in the audience approached me after to ask about Practice Fusion.  I was a little disgusted with my state medical association.  Then I realized how much money they make in advertising from these big vendors.  Silly me.

We doctors are suspicious folk.  When you tell us something is free, we want to know why.  NOTHING is free.  This is true.  All of those pizza lunches during residency weren't really free.  The price was an in-person advertisement from a drug company.  When you are hungry and have been awake for 36 hours straight, well, give me that pizza!  I asked some fellow docs why they were buying an EMR when they could have one free.  More than one responded that they were worried Practice Fusion might start charging for its services.  Hmmmm.  So they might charge one day so best to go ahead and pay another vendor.  Got it.  Wait, no I don't.

I'll admit I was suspicious too.  I had nothing to lose so I gave it a shot.  Sure enough, over the years, they have added scanned documents, e-prescribing, and even met their promise of "Meaningful Use".  I received my 18k deposit from Medicare a couple of weeks ago.  The support has been awesome.  It only makes sense.  If they make their money off advertising, more users = more money.  Ergo, they are Johnny on the spot when I need them.  The other large EMR vendors really don't have a reason to be responsive.  They have your money and a contract for more of your money.

So am I forcing myself to use something I hate?  Nope.  I love my free EMR.  I see my patients and print out the plan and email the prescriptions to the pharmacy before we leave the room.  At that point, Karla, my lovely assistant, already has a lab slip or card for the specialist I want and the patient gets all of that plus the printed plan.  Talk about convenient and efficient and a great way to keep your day moving.  The majority of refill request come through electronically and click, click I respond.  The majority of labs fall directly into the chart for me to sign off, click.  The majority of other documents are uploaded without ever making paper, from the digital fax service.  I swear I see trees smiling at me some days.

In summary, yes, there can be difficulties with the transition to an EMR.  I have found one with an easy user interface, with wonderful support and it is free.  There is no question that all of our medical records will someday be electronic in some form.  I am just glad that I found the EMR of my dreams before it was too late.  I am glad that innocent trees were not killed in the process.

Lastly, I must tell you that I do have a financial relationship with Practice Fusion.  They give me a free electronic medical record and I just got 18k from Medicare!  Whoopee!  Other than that, they do not buy me pizza or any other meals.  I have 18k to buy them myself.

Monday, February 6, 2012

Testing, One, Two...

I am having a hard time deciding on a subject for my very first blog.  I feel so tech-savy.  First I get a Twitter account and Tweet a few times, now my own blog.  Yet how to really distinguish myself...

I know:  I'll give you a glimpse inside the ADHD brain.

First, when I think of the word "blog" I think "blahhhh-g".  I am not really feeling blah, just sounds like blog.  Then I think of the word "bog", just because it rhymes.  Then I think of "The Bog of Eternal Stench".  Then Labyrinth, then David Bowie, Muppets, back to David Bowie (because he's hot), The Hunger, Catherine Deneuve, Shubert (music played by David Bowie in movie)... and I reach the end of that rabbit hole.

Lastly, I think of the word "log", because it also rhymes.  Log makes me think of very juvenile things like Beavis and Butthead, heh heh heh, heh.  I said log.  Heh heh heh.  Okay, if you get all of that you will probably get me.

So why have I decided to write?  Because I have nothing better to do?  Eating bon-bons and watching Erica Kane got old?  Actually, I feel I have something to contribute.  I am stubborn and willing to try to figure out anything and everything.  I am willing to ask questions that garner funny looks.  I have learned all about Asperger Syndrome, sensory disorders, starting a business, being an employer, health care reform, renovation a historic house... oh my the list goes on.  I continue to learn from my patients.  I am very interested in how to make people healthier with better balance and a return to old ways of living and eating.

So this is the end of the beginning, my very first blog.  Heh, heh.  I said blog.  More to come soon....