Let's analyze the analysis of the analysis and ask for more money

Dr. Makary, a surgical oncologist, has published an article in the British Medical Journal where the sensationalized clickbait headline is "Medical Errors account for the third leading cause of deaths in the US". There it is, making the rounds on NPR, nightly news talk shows, etc. Patients and politicians are freaking out on those crazy doctors killing us. Read the actual article here.

Just step back for a moment. This man is a researcher whose niche is analyzing medical errors. He's a surgeon specializing in cancer. He wrote the book on implementing checklists in the operating room, like pilots have pre-flight, where the surgical team takes stock of where they are, who they are working on, and why. This is now why whenever you enter the health realm, you're asked 50 times by 50 personnel who you are and why you're there, and patients harrumph back and give bad reviews on HealthGrades on how they were continually asked who they were.

Dr. Makary notably ends his paper bemoaning that there aren't ways to measure medical errors because WE DON"T HAVE THE ICD-10 CODE FOR IT. That's right, we need ANOTHER code for this and every hospital, death certificate, etc has to have a space where the code for what the medical error was that caused the patient death.  He tugs at heartstrings, citing I assume from his world, a case of a young woman who was a transplant recipient (soooo, wouldn't she be dead already if not for the transplant?) whose death eventually came from an error in the judgement of a procedure she received when readmitted to the hospital because she fell ill again.

THEN he bemoans the lack of funding for medical errors, his niche area, and hence his dearth of grant money.

OK. Dr. Surgical Oncologist, why aren't you writing about surgical oncology? Not operating anymore, because no patients. So he sat around chewing the fat with a friend, and in the dicussion they figured the way out for them was to analyze the analysis of the analysis (spearheaded by the oft quoted Institute of Medicine 1999 Medical Errors paper) and in so doing, extrapolated their findings to the whole population of hospitalized/sick patients.

I've had enough of being demonized and it being assumed that doctors are making so many errors all the time that it's a wonder anybody is alive.

No question that medical errors happen. No question that there's been a slew of soul searching and action from all of these papers, editorials, CME, safety committees--"pause and stop and think and remember where you are".  Use your checklist.

All in the 7 minutes the doctor is allotted to attend to Mrs. Smith.  Do it fast AND to perfection, every minute, every day. We are already doing it as fast and as perfect as we can. We have to comply with MACRA, MIPS, MU, EHR mandates, 5-figure malpractice insurance premiums, our corporate bosses telling us speed it up or we're fired, denial of payment for actually rendering a service to the patient, calling them back, imploring them to take their meds, listening and comforting when they're in pain and infected and not doing too well. Overdose.Retire. Walk away. Suicide. We can't do it anymore.

How about the EHR errors? How about the government errors? How about the pharmacy errors? They all get lumped and dumped into medical errors. See what they did here. Medical is the root cause of all evil, and lets' get them out of the way.

I'm not sure who is actually going to be left to do the transplant. I hope when my time comes for real serious medical care, there's someone left who can fix my troubles, not MACRA, MIPS, MU, checklist charlie.

The Power Went Out

I decided years ago I wouldn't adopt an EHR. Yes, I use paper charts, with my own hand drawings for the purposes of illustrating TO MYSELF AND THE PATIENT where the suspicious lesions are geographically on their bodies. The lack, of and often nonsensical, governmental communications regarding HIPAA policy on storing, managing and receiving sensitive patient data electronically stopped me. I also practice on an island. Some may think it's paradise. But paradise doesn't come with buried electrical cables, and every tiny windstorm, thunderstorm, or power surge causes our power to go out, and it's always at 10am, in the heat of clinic. I cannot function without electricity, so I close for the day. I can still think, and write by a window for light, just like in the time of Adams. But I can't click away. God bless my colleagues who try. This is why they're quitting and leaving a shrinking pool of doctors or clinics who can accept new patients. The lack of control and endless frustrations with simple infrastructure is driving physicians out of the field entirely.

But I digress.

I searched a bit online, just for fun, about the whole flurry of excitement circa 2008 on EHR. It seems everyone was pushing for EHR implementation, and right quick, with no thought or consideration. Epic is the largest and the most profitable software vendor, contracted to Kaiser Permanente, Mayo Clinic, and lots of other illustrious medical centers. It's got to be good, right? With the imprimatur of world class institutions as clients, and a little old fashioned bribery, it took off.

Here's some interesting reading about the history/origins of Epic--click here.

Here's Michelle Malkin's (love her) pitbull terrier assessment from 2013: click here.

It gets better--she researched that Epic has the lock on EHR for the Dept. of Defense and the Pentagon. The health records of the military. The cake was big, and everyone had a slice at the party: click here.

These weak systems are being hacked for ransom by cybercriminals. A hospital in LA got hacked and held ransom for 17K in Bitcoins--smart financial move with the weak dollar. AND THE HOSPITAL PAID IT AND GOT THEIR RECORDS BACK. We are not privy to the information on where are the hackers, who are the hackers, are they in Ukraine? Panama? Peoria? This info isn't for the plebs. Nothing to see here, keep moving.

Who hasn't gotten a letter that their health information was hacked? I got one from the center where I got X-rays,  and my patients regularly get them from other doctors and hospitals and they ask me about it. I tell them that since I don't use EHR's, there is 100% chance that my records won't be hacked. I tell them we're all pawns in the machine. They get unhappy when I say this, like the kid yelling in the playground that there's no Santa Claus. Sorry folks, reality is where I live, wake up and smell it.

Now I see commercials from IBM touting Watson and the supercomputer that beat Jeopardy! It will one day be our collective physician. Look, physicians use it to supercompute through patient data! And the data show the patient had his seatbelt on and the shingles/pneumovax/flu shot!!

Can Watson evaluate the fingernails of a patient with factitial dermatitis, just like Sherlock's sidekick used to do --NO (literary fiction folks, Sherlock Holmes was not real--this is for the Millenials, the group we love to hate). Can Watson smell the alcohol on the breath of the limping white haired man with a total body skin rash for years? No.

Don't tell me it will take my place.

Care, But No Care

It never ceases to amaze me how much "care, but no care" I see from patients who come in with horrific skin conditions. They've been to 3-7 "doctors"--in reality, 3-7 nursing assistants or nurse practitioners supposedly working under the wing of a physician--this is never the case. They're confused and can't tell me what they have been told, diagnosed with, much less prescribed. They certainly got asked about their flu shot, seat belt, sunscreen usage, etc. heck a skin cancer screening was done!-- but the core issue they came in to get treatment for fell by the wayside. They have very extensive and severe dermatological conditions which require deep and thorough evaluations and work-ups. I request medical records. Sometimes I get them. More often I don't, and I have to start from scratch. It's easy to "start" because literally, nothing has been done. Patients look at me with eyes wide as saucers when I tell them I'm going to need to take a skin biopsy. I think they imagine a sledgehammer or cleaver behind the closet door to take the skin biopsy, and they're beyond shocked at how simple and quick it is for a SKILLED physician to do. No infections or extraneous bleeding all over the floor. Dermatologists do it clean. Would you ask the plumber to fix the oven? No.

I tell them this will be a process and that together, we will find a way to treat their skin problem. They tell me they were told "to put Vaseline on it".
EYEROLL.

Why is this happening? How did this happen?

My assessment: it's not heath care, or medical care, any longer. It's patch and turf, get the data into the EHR, collect the bonus. Punch the clock. Kick the can down the street. I'm tired and I want to go home.

This is deeply concerning and destructive. Doctors are quitting medicine altogether in droves. With no representation and no power "at the stakeholders' table", it has been widely documented that doctors nearing retirement have accelerated the process, and increasingly doctors in their prime are quitting medicine altogether. The AMA has long stopped representing physicians. It is a bewildered anachronism with a core mission to "improve the health of the Nation"--a big mission, nothing about protecting the doctor. I know of many who have quit lucrative medical careers and started yoga studios, vegan food services, medi-spas, health coach. Doctors are smart self-starters. They get tortured with EMR's, ICD 10, ACO (administrative) nurses with clipboards tallying the counts on the PQRS measure, and endless documentation bullshit. For doctors, money isn't the issue. It's about ownership of your skills and TIME. So they quit medicine forever. The tunnel narrowed and for these doctors, it was time to jump ship for sheer survival.

The latest most dangerous game: please the patient above all else so they give the clinic/hospital/staff 5 stars on Healthgrades or Yelp surveys. This includes the handing out of narcotics, to keep the masses comfortably numb and more apt to give a favorable online review. This is happening.

This isn't flying a plane. This isn't assembly of Toyota cars. This isn't an ATM transaction (although many would beg to differ). This is down and dirty, elbows-up-to-the-guts REAL LIFE. We witness birth and death. Pain, infections, cancers. Broken bones and broken hearts. Every human ailment, whether physical, mental, genetic, environmental. Populations don't get sick. Individuals get sick, and us humans are as infinitely different and crafted as nothing else in our world. We have free will. We can choose to take the pill, or not. To smoke, or not. And so doctors or clinics cannot be held accountable when the smoker gets readmitted for pneumonia while smoking 2 packs per day. Are clinic staff to go home with the patient,  following them around and being like a prison warden, cutting off the cigarette supply? Only 25% of ACO's have turned a bonus. That means 75% haven't earned a penny in "incentives for coordinating and streamlining duplicative care and producing efficient quality care". I suspect what's actually happening is a lot of hand waving and boxes being clicked, but no substantive results on anything. Florida Medical Association put together a concise article with startling statistics.

http://flmedical.uberflip.com/h/i/233300395-florida-medical-association-magazine-spring-2016

This is a giant waste. The maw of this monster must be stabbed, like St George slew the dragon. Doctors must regain the courage to say NO. I will not click the box. I will not see 78 patients in 6 hours. I will not work for free. Weekends belong to me now. I will not do a preauthorization, iPledge, online data entry, "in between patients". We must start saying no and we must start pushing back. Many already have. I'm just afraid that when it comes time for ME to have medical care, I will be turfed to the system that punches the card, in and out.

Thank you Government. Thank You Corporate. You've made lovely bedfellows. It's time to burn the bed.

Government largesse: the shell game

The current (version 174.5) acting head of CMS, Andy Slavitt, was a former CEO of Ingenix, a division of UHC. They were indicted in New York for operating manipulated databases with fraudulent reimbursement schemes pertaining to repricing out of network claims. (Complicated, I know, just stay with me here for a minute).
This same Mr. Slavitt now heads the government agency responsible for Obamacare, Medicare, and Medicaid. Not sure how that job interview went, but here we are. After much spouting about the wonders of Health Tech, Health It, EHR, Meaningful Use, etc. a stunning about face came about last week. Meaningful Use has been a pure torture device for doctors and clinics, the EHRs are so cumbersome and difficult to access. I personally tried to access my own patient portal when seeing doctors and they're buggy, circa 1991 FORTRAN in look and feel. The website for any consumer goods merchant is far more interesting, easy to access and interactive. I wouldn't dare ask an octogenarian patient to go log on or do whatever it takes to qualify. It's just not right, and for what purpose? Where is this all data going? what is the bribery or kick back for? Perhaps to close the loop on Epic-->money to congress-->law enacted in their favor-->crumb thrown at doctor for shelling out $100K on EHR.

Read about it --

In light of comments last week from Centers for Medicare & Medicaid Services (CMS) Acting Administrator Andy Slavitt on Meaningful Use as a component of the Medicare and CHIP Reauthorization Act  of  2015 (MACRA) and the Merit-Based Incentive Payment System (MIPS), Mr. Slavitt and Karen DeSalvo, MD—National Coordinator for Health IT—prepared a January 19th blog post that included the guiding principles of how the Meaningful Use Program will fit in with MACRA implementation.  

Mr. Slavitt and Dr. DeSalvo’s blog identified the following principles for the future of Meaningful Use, health IT, and physician value-based payment

1. Rewarding providers for the outcomes technology helps them achieve with their patients.
2. Allowing providers the flexibility to customize health IT to their individual practice needs. Technology must be user-centered and support physicians.
3. Leveling the technology playing field to promote innovation, including for start-ups and new entrants, by unlocking electronic health information through open APIs – technology tools that underpin many consumer applications. This way, new apps, analytic tools and plug-ins can be easily connected to so that data can be securely accessed and directed where and when it is needed in order to support patient care.
4. Prioritizing interoperability by implementing federally recognized, national interoperability standards and focusing on real-world uses of technology, like ensuring continuity of care during referrals or finding ways for patients to engage in their own care. They stated they will not tolerate business models that prevent or inhibit the data from flowing around the needs of the patient.

Mr. Slavitt and Dr. DeSalvo’s blog also emphasized several important points for the physician and hospital communities, including how current law requires that HHS continue to measure the meaningful use of Office of the National Coordinator (ONC) Certified Health IT under the existing set of standards. Although MACRA does provide an opportunity to adjust payment incentives associated with electronic health records (EHR) incentives in concert with the principles that they outlined, it does not eliminate the EHR Incentive Program, nor will it instantly eliminate all the tensions of the current system. CMS and ONC vowed to continue to listen and learn and make improvements to these programs based on what is happening in the field.

In addition, MACRA only addresses Medicare physician and clinician payment adjustments. The EHR Incentive Programs for Medicaid and Medicare hospitals have a different set of statutory requirements and are not directly impacted by MACRA. Mr. Slavitt and Dr. DeSalvo will continue to explore ways to align the principles they outlined for physicians with hospitals as well as the Medicaid program.

Moreover, their goal in communicating these principles at this point is to give all stakeholders time to plan for what’s next and to continue to give CMS and ONC input. They encourage the entire community to review the MACRA regulations this year; in the meantime, existing regulations—including meaningful use Stage 3—are still in effect.

The blog also discussed how Congress, in December 2015, provided HHS new authority to streamline the process for granting hardship exceptions under the Meaningful Use Program. This new paradigm will allow groups of health care providers to apply for a hardship exception instead of each doctor applying individually, which should make the process much simpler for physicians and their practice managers in the future. Mr. Slavitt and Dr. DeSalvo promised to release guidance on this new process soon. 

Lots of words, little tangible information. 

Never Mind the Bullous

Heard from a colleague across the country about an elderly patient with blisters covering her feet and unable to walk, unable to function. Many visits to doctors, ER's and no continuous care, no management. Finally went to a cash only practice where the doctor listened, examined, treated. This no longer happens at practices that serve everybody at all times. Unable to even get a follow up appointment! I'll bet that patient was asked many times by "staff" at the other ER's and derm practices whether she had her flu shot or wore her seatbelt, like good comrades they had they her fill out the customer care survey. Never mind the pemphigoid. ****** the Sex Pistols "Never Mind the Bullocks"!!!!!!******

This patient was seen once by an actual physician---all other visits were conducted by assistants and "providers" who can't possibly know how to diagnose such a thing; they patched her up with maybe a top. steroid and Cephalexin and turned her out. She got worse and developed complications. It's sad, and not uncommon. 

I've seen very similar things here, once for example, where a man was told he had condyloma on his penis, and for several visits at other practices the ARNP/PA performed cryo on it; the scab and ulcer never resolved so 2 months later he came to me, where I spotted grouped vesicles below the scab. Herpes simplex. He never saw a physician all the times he had been to other offices, and he had an HMO plan I do not participate with. He was very angry at the others, as he should have been. Another elderly woman with Medicare was given top. steroids FOR YEARS to apply to the scaly patch on her cheek. I biopsied it on the first day and it was SCC, she needed extensive Mohs and reconstruction. I accepted her Medicare too. But at the other places she rarely, if ever, saw a doctor. 

The system is set up for volume, graft, lying, and nonsensical care. Government mandates, insurance companies covered items, non-covered items, all changing on a monthly basis; Obamacare, Medicare HMO's, etc have destroyed medical care in the US. Our voices have been drowned out because we are in the trenches doing what we do best. We rely on our organizations, not entirely, but still, to communicate to the power elite what is happening in real time and what to do about it. They have all colluded in creating a monster, with flow charts, EMR, nonsense and irrelevant "quality care" mandates, and penalties. The AMA and AAD sells lots of books and CD's on how comply with the mandates. They rolled over and surrendered. So I have ended my membership with them. 

Another dermatologist friend was freaking out when her boss was making them do PQRS at the end of 2015. She spent hours on the phone calling up her patients and asking if they had their flu shot. Not to then admonish them nor administer it, simply a box had to be checked in the software and she felt she could only do this truthfully by calling them at home, and asking them. Think about that. A board certified dermatologist who can cure complex skin CANCERS and disease and diagnose from the doorway, was reduced to this. What a waste!!

The pie of decent doctors taking Medicare will disappear, and the only pie left will be the churning, take a number, inferior clinics--staffed by who knows who-- that will accept Medicare but not cure disease. Hence the two tier system we are talking about, it's here. We are in it.  

 

All I can do is periodically email congressman and women, I even called the White House one particularly maddening day and I screamed at the operator--and I tell my patients openly and honestly what's going on. They don't get it. They have very busy complicated lives, they just want "to go to the doctor and get this taken care of". They have no clue that it's not about them anymore. 

You better not be telling me what to do

Interesting and shameless recent patient interaction. He comes in once a year, maybe. The last visit was 18 months ago, because "I don't like paying the $35 copay".  This patient has a $0 cost (to him), Medicare Advantage plan with a company currently embroiled in a merger deal with another big five company.  I say, "well, I don't like working for free". He says his INSURANCE agent (who gets a commission for every policy sign-up) told him to "tell the doctor to send in the claim as a prevention visit and it would be covered 100%". I told him to go to his agent for his future medical care, and I was only half joking.

Where to begin?

Doctor comes from the latin word, docere, meaning "to teach". I teach prevention at every visit. As a dermatologist, it boils down to the basics that everyone hears all day--stay out of the sun, wear sunscreen, stay hydrated, moisturize. We're not talking about a 30 year old coming in for a check up and wants to know how to take care of herself. We're dealing with an 88 year old man with a history of dozens of basal cell skin cancers, squamous cell skin cancers, many Mohs surgeries, a chart rife with biopsy report after biopsy report.

I am an end of the line specialist for this patient, firmly in the realm of management and treatment for skin cancer. Referrals get made annually for him for Mohs surgery for those skin cancers that are too aggressive, irregular, located in tough spots such as the eyelids. Every visit for the past decade involves a diagnosis and a treatment. Preventative advice is freely given, and never followed. This is the same patient who told me 4 years ago he would sit in the Florida sun for 30 mins every day so he would get his vitaminD. This is on the same day I excise a basal cell skin cancer from his face. After telling myself to stay calm, I advise him that it's a bad idea to sit baking in the FL sun, with his Caucasian-white and terribly sun ravaged skin. Broken bones resulting from low levels of vitamin D can be prevented by taking a daily vitamin. There's no such remedy for skin cancer. The damage was done decades ago, when he was self professed sun worshipper, visiting FL from the northeast where he would come down and get sunburnt, then go home and show off his tan. ***eyeroll***

We are long past the point of submission of "prevention visits" for this patient. We are in the business of keeping him alive and well and not letting him succumb and suffer from readily treated skin cancers. We are also not in the business of following the exhortations from a salesman. Borderline fraudulent, the falsehood perpetrated by this agent feeds into the whole gestalt in our culture right now, "I need to get something for nothing". This isn't possible. If I don't collect the copay, I lose money, and on a grander scale, I may need to close my practice if I take a 15% fee cut across the board from all my patients with a copay. Then where would we be? No doctor, no help, increased morbidity and mortality in a community. All from an agent who thinks he can help us all "game the system" by getting something for nothing. I'm not going to justify my business costs, nor defend my ability to stay in business, by allowing a bottom feeding salesman piece of trash to tell a patient to tell me what to do, and how.

To add insult to the injury, medical records are often audited by this same company's "provider payment integrity department", and if the record doesn't fit congruently with the medical claim, recoupment of payment is initiated. No recourse, no contest. The money is garnished from future earnings or sent to a collections agency, and a blemish on your financial record forever. So you see, I'm on the hook after the payment is made to me, by the insurance company, for my integrity and honesty --or I sink like the Titanic.

This story hasn't ended. I am waiting for the call from his agent. I can't wait for it, actually, it's going to be soooo fun to deal with this one.

CEO Helmsley--go get your pity sandwich yourself

Steven Hemsley Total Compensation 2014:$66,125,208 (Source Star Tribune)
Steven Hemsley Total Compensation 2013:$14,856,321
Steven Hemsley Total Compensation 2012:$34,721,122
Steven Hemsley Total Compensation 2011:$48,800,000
Steven Hemsley Total Compensation 2010:$102,000,000 (Source Star Tribune)

http://www.startribune.com/unitedhealth-ceo-stephen-hems…/…/

Total compensation for 5 years: $266,502,529
---comprised of stock and cash, directly siphoned from govt/taxpayer funds for Obamacare, bundled contracts, and probably less so from individual premiums.

Total compensation for Winnipeg Regional Health Authority CEO (Canada) $120,000 a year. (Source-- Glassdoor)

I love capitalism, America, and success, but this is crony capitalism, pork, corruption, and everything soul and life-sucking about our times.

This is the same CEO bleating about how much money UHC lost through Obamacare exchanges, and kicked yours truly off the Medicare Advantage Network because Dermatology isn't a medically necessary, cost effective (for them) "controllable" specialty. Tell that to the skin cancer patients in FL--it's an epidemic here.

I don't need you, UHC, at all. In fact, I'm happier and more productive off your network than on it.

http://www.modernhealthcare.com/article/20151119/NEWS/151119858