Better Health (Dr Val’s organization, of which I am a small idler wheel) is at HIMSS10, doing interviews.
It’s entertaining, you can ask questions of the interviewees through the chat stream, so it’s interactive.
Broadcasting here: USTREAM.
Ramblings of an Emergency Physician in Texas
Better Health (Dr Val’s organization, of which I am a small idler wheel) is at HIMSS10, doing interviews.
It’s entertaining, you can ask questions of the interviewees through the chat stream, so it’s interactive.
Broadcasting here: USTREAM.
Dr. Bukata has long been a leading light in EM, and it’s my pleasure to present:
THE SECRET TO UNIVERSAL HEALTH COVERAGE – DOCTOR BEHAVIOR
As the debate goes on regarding the Obama initiatives for healthcare reform, the one recurring theme that is heard is – cost. What is universal access to healthcare going to cost and who is going to pay for it? It really is just about money. The fundamental premise is that, if we spend at current rates, it will cost an ungodly amount of money to cover everyone in this country no matter who pays.
Given that we cannot continue to spend at the current rate, yet we want to insure the 40 million people or so who have no insurance (and all of this is supposed to remain budget neutral over time), the logical answer regarding cost must be reducing per capita spending while increasing the number of people covered.
How do we achieve this goal? There is really only one way. The answer is to narrow practice variation. Practice variation between doctors is absolutely huge. The data are compelling. Even small changes in the degree of practice variation have the potential to save hundreds of billions. I refer readers to an article in the New England Journal of Medicine by Elliott Fisher, et al (360:9, 849, February 26, 2009). The article is entitled Slowing the Growth of Health Care Costs – Lessons from Regional Variation. This short paper gives examples derived from the Dartmouth Atlas on Health (which I have referred to in the past and which is absolutely fascinating reading concerning Medicare practice variation nationally) that make it clear that doctors are major determinants of healthcare costs. We order the tests, we order the drugs, we put people in the hospital and we determine where they go in the hospital and, to the chagrin of hospital administrators, we determine how long they stay.
Using Medicare as an example, at our current rate of spending growth in healthcare it is estimated that Medicare will be in the hole by about $660 billion by 2023. If per capita growth could be decreased from the national average of 3.5% to 2.4% (just a measly 1.1%), Medicare would have a $758 billion surplus. Just a measly 1.1%.
Now for some examples. Per capita inflation-adjusted Medicare spending in Miami over the period 1992 to 2006 grew at a rate of 5% annually. In San Francisco it grew at a rate of 2.4% (2.3% in Salem, Oregon). In Manhattan, the total reimbursement rate for noncapitated Medicare enrollees was $12,114 per patient in 2006. In Minneapolis it was $6,705.
It is noted that three regions of the country (Boston, San Francisco and East Long Island) started out with nearly identical per capita spending but their expenditures grew at markedly different rates – 2.4% in San Francisco, 3% in Boston and 4% in East Long Island. Although these differences appear modest, by 2006 per capita spending in East Long Island was $2,500 more annually than in San Francisco – with East Long Island representing about $1 billion dollars more from this region alone.
Are the patients sicker in East Long Island? Hardly. There is no evidence that health is deteriorating faster in Miami than in Salem. So what’s the difference? People point to “technology” as being one of the biggest sources of costs in American healthcare. But “technology” does not account for these regional differences. Residents of all U.S. regions have access to the same technology and it is implausible that physicians in regions with lower expenditures are consciously denying their patients needed care. In fact, Fisher and colleagues note that the evidence suggests that the quality of care and health outcomes are better in lower spending regions.
So what is the answer? It is physician behavior.
It is how physicians respond to the availability of technology, capital and other resources in the context of the fee-for-service payment system. Physicians in the higher cost areas schedule more visits, order more tests, get more consults and admit more patients to the hospital. Medicine does not fit the supply and demand model of modern day capitalism. Normally when there is lots of competition, prices go down. Not in medicine. In medicine payment remains the same and is not sensitive to supply or demand.
And normally when there are a lot of businesses providing the same service, there are fewer customers per business. Not in medicine. Although doctors may have fewer patients in an area saturated with providers, they don’t necessarily have fewer visits because doctors determine the frequency of revisits and the literature indicates there is huge variability in what they consider the appropriate frequency for revisits when given identical patient scenarios. And do patients shop prices to choose medical providers – no way – it is impossible. Bottom line – medicine is largely immune to the laws of supply and demand and other economic drivers.
So what’s the answer? It is simple, yet hard. Doctors in high cost areas need to learn to practice like doctors in low cost areas. Are doctors in low cost areas beating their chests and bemoaning the inability to care for their patients with the latest technology? Not at all. But doctors in high cost areas are largely clueless to the practice patterns of physicians in low cost areas and are likely to whine if asked to tighten their belts and learn to be more cost-effective. The good thing – mathematically, this will result in only half the doctors in the country complaining as they are prodded to emulate the practices of their more cost-effective cousins.
To accomplish this narrowing in practice variation, doctors will need help (and, particularly, motivation). Payers and policymakers will need to get involved to facilitate and stimulate the information transfer between doctors. Based on research by Foster and colleagues, it’s advised that integrated delivery systems that provide strong support to clinicians and team-based care management offer great promise for improving quality and lowering costs.
Given that most physicians practice within local referral networks around one or more hospitals, it is suggested that they could form local integrated delivery systems with little disruption of their practice. Legal barriers to collaboration would need to be removed by policymakers and incentives to create these systems would drive their formation.
Fundamentally, Medicare would need to move away from a solely volume-based payment system (since doctors are the drivers of their volumes) and other forms of payment would need to be incorporated (such as partial capitation, bundled payments or shared savings). Hospitals and doctors lose money when they improve care in ways that result in fewer admissions, and they lose market share when they don’t keep pace in the local “medical arms race” (does everyone need a 64-slice CT?). In the current system there are no rewards for collaboration, coordination or conservative practice. This must change.
The bottom line – much can be done to save money yet provide patients with high quality, technologically advanced care without rationing (or worse yet having some government “board” telling you what to do). There is so much waste in the current system largely resulting from physician practice variation that the opportunities are huge.
And, should they choose, doctors are in a position to take the lead. The AMA and other physician organizations can initiate (well, that may be asking a lot) and support incentives that will facilitate the needed changes outlined above. Unfortunately, organized medicine (almost an oxymoron) is more often than not reactionary. “What are they (payors) making us do now?” That’s the typical response. What’s needed is for physicians to take the leadership role that their patients expect of them. The status quo is not an option. And if doctors won’t act, the payors will – because ultimately, the payors have the power. That is one rule of economics that does apply even to the practice of medicine.
W. Richard Bukata, MD
I respectfully disagree about markets not working in medicine, but have few arguments with the rest.
What say you?
Please take the time to vote in my polls so I can learn a little bit more about who you are. To be honest, I’ve never really known WHO my audience was at my former blog at Revolution Health. I just kept chirping away, with the occasional comment/feedback. Now that I have my own site I’ll be interested in getting to know you better, just as some of you have gotten to know me over the past few years.
It’s a good thing, too!
Well, I learn something new every day from blogging. Thanks to TBTAM for the wart therapy tip: pregnancy can cure warts? I’m not sure if I’m THAT desperate yet. And what would I say to my child – yeah, daddy and I didn’t really want to have a kid, we just wanted to cure our plantar wart? Lol.
Here’s an ER themed cartoon for you trauma folks. Enjoy!
As many of my close followers know, I’m “in between blogs” at the moment. My new website has not launched yet, so I’ve asked a few close friends if I could guest-blog at their sites until further notice. Dear Grunt Doc actually offered me a password and authority to post directly to his blog. Now that’s trusting! I mean, I could fill up his site with LOLcats posts if I wanted.
A few blog-hijacking fantasies later, I decided to ask myself – “What sort of content would be appropriate to contribute to an Emergency Medicine blog?” The answer, of course, is “real photos of anything gross.”
And as luck would have it, I do have a nice photo of something gross (albeit mildly so). Even better, it’s my own grossness so there’s no HIPAA violation looming. What is it? Well, it’s the sadistic work of a dermatologist. (By the way, dermatologists have the best photo galleries of really gory conditions).
Let me explain.
You know how every once in a while in life you think, “Gee, this is a really bad idea” but then you go ahead with it anyway? That happened to me 7 years ago. I had accompanied a friend to a hair salon in Rochester, New York. And since the process of having her hair colored would take about 2 hours, I figured I’d find something to amuse myself. The salon offered manicures and pedicures. So I opted for a pedicure.
A little voice inside me said, “Is it hygienic to do a pedicure in a plastic tub with tools that don’t look as if they’ve been sterilized?” But then I figured, “it’ll be fine.”
A few weeks later I noticed a plantar wart on the heel of my foot. “Crap. I guess I’ll just go and have my PCP freeze it off.” Sounds easy enough – but 7 years later I have to tell you that this wart virus is still alive and kicking. Here’s what I’ve hit it with:
Liquid nitrogen Q month x 24 months, salicylic acid pads QD x 12 months, duct tape, OTC wart spray, podofilox topical solution, aldara cream (costs $500/3 month supply), bleomycin injection (that’s the chemo that can cause pulmonary fibrosis), and now blistering acid solution.
I had the “blistering acid” applied yesterday. And it’s 4:30 am and I was awoken by a sharp pain in my foot. So I got up and saw – you guessed it – blood blisters on the bottom of my foot. Yum! Not to be outdone by Paul Levy, I snapped a photo for Grunt Doc’s blog, feeling very satisfied with my contribution.
Here it is:
What on earth is the moral of this story? Ladies (and a few gents), if you have any doubt about the hygiene practices of your local nail salon – do NOT override your instincts. Just remember my story, and how I discovered the virus that will survive a nuclear war. If this series of blistering acid treatments doesn’t do the trick, I’m coming to GD’s ER for a wide excisional biopsy. God bless EMTALA.
P.S. If the injury site begins to look really gross, I’ll snap you another photo!
Apparently, international emergency medicine isn’t for the faint of heart. And I’m not talking about CHF. You’ve gotta have guts. I found it interesting to learn that the greatest risk in practicing international emergency medicine is not that one might catch a communicable disease, but that one might die of physical violence. This according to Dr. Hilarie Cranmer, Clinical Instructor, Division of International Health and Humanitarian Programs at Brigham and Women’s Hospital in Boston. In fact, physical violence against humanitarian workers is on the rise, and it is increasingly targeted and intentional. The red cross, which was once a symbol of protection, has become, for many, a target.
“We all want to save the world,” said Cranmer, “but you’re at great risk for doing so.”
Then again, emergency medicine isn’t a specialty for the risk-averse. I look around and see a lot of men and women ready and equipped for the challenge.
First of all, a special thanks to GruntDoc for allowing me to host the blog this week while I attend the ICEM conference in San Francisco. A short travel story, without which any conference coverage would be incomplete. My wife and I arrived in the Bay Area last night after an uneventful flight and then promptly hopped into the cab from hell. Our driver looked sweet enough as we climbed in the car, but then we discovered that his right foot was made entirely of lead. He hurled through highway traffic at 90 mph. I kid you not. 90. In traffic. Let’s just say I’ll have to leave my scenic viewing of the Golden Gate Bridge to another ride.
But on to the show. ICEM is put on in coordination with the International Federation of Emergency Medicine (IFEM), a group which began as a small collection of countries with highly developed EM systems, but which has exploded in recent years. The meeting rotates through member countries, and the landmark international gathering will not take place in the United States again for at least 14 years. The conference will celebrate a year of unprecedented progress in the advancement of emergency medicine around the globe, such as in India where the specialty has finally made serious inroads thanks to the efforts of a little group of physicians called the American Association for Emergency Medicine in India (AAEMI). I have no doubt that the EM developments around the world will have far-reaching affects on the specialty in the United States.
I was pleased when I opened my mailbox today, and the new Academic Emergency Medicine burst out. It’s really a treat, on par with my subscription to the New Yorker. Why? Because AEM really expands my concept of what research, and emergency medicine, can be. I’m not kidding, and I’m not damning by faint praise (and EM is too small a community for me to get away with it, if I were).
The first article that caught my eye was entitled, Laser-assisted Anesthesia Reduces the Pain of Venous Cannulation in Children and Adults. Now, over the past year I’ve become pretty good at starting IV’s, I’m starting to incorporate ultrasound guidance on some tricky, urgent cases. But I’ve never really focused on minimizing pain, as my patients can attest. In the OR I’ve seen the anesthesia residents sometimes use lidocaine (and I certainly give it before a spinal tap) but I had no idea lasers were an option. Apparently, using a handheld laser over the planned IV site will ablate th topmost layer of skin, allowing transdermal anesthetics to seep though. Patients reported less pain in a randomized controlled trial (the patients and researchers were also blinded, though it’s not clear whether it was by design protocol, or from the power of the lasers).
Anyway, the next time I see an administrator strolling through the ED, I’m going to ask for a handheld laser. The evidence supports it, patients love it, and I’ve always, always wanted a laser gun.
Another eye-catching study was called, Single Question about Drunkenness to Detect College Students at Risk for Injury. The question was, "Hey, buddy, want to go grab a drink?"
Ha! No. I kid. The question was "In a typical week, how many days do you get drunk?" Any answer greater than or equal to "1" was associated with a fivefold increase in EtOH-related injury, a more than twofold increase in falls requiring medical treatment, and a more than twofold increase in being sexually assaulted. It’s a better marker than binge drinking, or anything else out there. The study was limited to ten North Carolina colleges — we’ll see if it’s generalizable beyond that. But the ED is a great place to make an intervention in a young college kid’s life, and this one question is a heck of a start.
It’s not all great in this month’s AEM — I was a little disappointed that Childhood Injuries Caused by Falling Televisions didn’t contain any blockbuster revelations (did you know there’s no ICD-9 code for falling televisions? for shame!) but on the whole this journal kind of inspires me. Anyone else out there a fan of AEM?
What would GruntDoc do today? Why, link to this week’s Grand Rounds, and give an excerpt!
Not until the last moment did I realize that my Grand Rounds falls on a day of apocalyptic significance, celebrated by some. My hope is that TMBN’s new ideas will not cause the end of the world and instead bring us "Hell of a Grand Rounds"!
Amen to that. Tune into the Medical Blog Network’s edition of Grand Rounds, and see what everyone in the medical blogosphere is talking about. My interview with Dmitriy Kruglyak is available on Medscape (registration required).
Hello, GruntDoc readers! This is my first guest-blogging stint, but I’m a big fan in general of neighborly community behavior. We have friends pick up the mail for you when you’re away, maybe feed the cat, so why not maintain the online presence, as well?
Especially when the online presence is that of GruntDoc, who’s been a dedicated supporter of medical blogging in all its forms, including Grand Rounds (he is a three-time host, I interviewed him once for Medscape). GruntDoc has also been a source of tips and commentary to MedGadget, another blog I contribute to (in fact, when we got the tip about this cricothryroidotomy keychain, I immediately thought of him).
GruntDoc encouraged me to rant during my stint here — I think he’s trying to keep things lively, or maybe he knows how much I have to reign it in usually, as an intern blogging under my real name.
I’m not sure this is a rant, but I do want to address Symtym’s assertions on what’s really an emergency. He quotes a figure I’ve heard, and verified — 100 million visits to US Emergency Departments each year (I’m getting numbers from Richardson AEM Vol 40, p 388).
100 million A huge number, to be sure, especially given the US population of 300 million. So it’s easy to say we’re in crisis now, everything is an emergency, forces have conspired to make people think they should use the ED for hangnails and stuffy noses. right? guess Well, guess how many visits were logged fifteen years ago: 90 million.
OK, now maybe there was wild misuse of emergency services in the early 90’s, too (I wouldn’t really know, I was in high school). It seems, though, that the problem isn’t that there are more people using ED’s inappropriately, or at least, this isn’t a terribly new issue. Rather, it’s that there are fewer ED’s around, so we’re all feeling the crunch more.
As for those 100 million visits, does that really mean that one third of all americans go to the ER each year? Of course not. Me and my two friends sure don’t, least not yet this year. Meanwhile, I can personanly vouch that some of our "regulars" chronic homeless alcoholics use the ED 100 times a year. How big a problem is this? I’ve blogged about it before, it’s a big problem and accounts for a substantial fraction of ED expenditures.
What about all the 70-year old diabetic hypertensives with chest pain? They come in every three or four months with disturbing symptoms. The 80-year olds who feel week and dizzy, maybe they blacked out for a second. These are real complaints, real emergencies, they need workup, every time.
As for the hangnails, the inappropriate use of ED services, it’s actually notoriously hard to calculate how many are seen inappropriately. People have tried (Richardson, again — maybe I’ve worked with her, once or twice). The bottom line is, it’s hard to measure inappropriate ED use, and efforts to deny care to non-emergent situations may end up costing more, and/ or causing bad outcomes. Researchers try to quantify it, but existing denial of care methods just don’t seem to be worth it, and the estimated savings may be exaggerated as well.
You can blame "themes of entitlement" and whatnot, and I’ve found doing so provides some comfort when you’re stressed and feeling put-upon by those few demanding, unappreciative patients. But, when you really look at it, it’s hard to blame the patients.
And, you know, as an intern, I’m going to get paid the same living wage whether I see a dozen patients a shift, or two dozen. But I keep trying to move quickly, providing good care and pleasant bedside manner, because I want to see as much as I can, and I’d like patients to get a favorable impression of our hospital and ED. If they end up realizing that we, in the ED, can provide services faster and more completely than if they just showed up unscheduled to their primary care doc, well, good for us.
Look, I’m not trying to debate ED access or government incentives to waste — that argument sprouts up every few weeks on the blogosphere and there’s already a good iteration / continuation in progress over at Grahamazon. I’m just trying to, well, figure out the right mindset and perspective to approach my job, and avoid becoming as jaded, down the road, as some others appear to have become.
To answer the question (“Hey you in the ER! Is this really an emergency?”)—of course not! Historically the utilization of the “ER” runs 35% of the US population, or roughly (and presently) 100M annually. We lives in an exceedingly dangerous and ill society if we believe that one-third of our society has a “true” emergency requiring the services of an “ER” every year. Additionally, in many urban settings, 25% of ER volumes are brought to the ERs by ambulances. Again, we live in a very dangerous and ill society if we believe that one-twelfth of our society is so impaired that an ambulance is required every year.
For many reasons, the ER is the US healthcare system’s equivalent to fast-food. Similarly, the ambulance, often referred to as a cabulance—is just a form of door-to-door public service. Addicting? Essential? Fundamental? A right? A waste? Why? All very fair observations and questions, and I believe all come down to what we have incentivized in our society, directly and indirectly.
For those that utilize the ER and truly perceive every pain, malady and bodily dysphoria (theirs or those they decide for) to be true emergencies it is hard to fault that as inappropriate. I consider that appropriate “overreads” for a kind society and related to all the PSAs that promote self-awareness of healthcare issues. They get an “A” for intent, but only a “C” for excution—but reasonable, when we want a system that should be based on sensitivity trumping specificity.
If you consider all governmental funding sources for healthcare equivalent to a zero-sum game, then I believe it is easy to understand why both the feds and the states are increasing the pressures on the Medicaid programs. It has nothing to do with state surpluses, because the feds and the states share equally in the Medicaid yoke. But (IMHO) has everything to do with where governmentally-derived healthcare spending will need to go—Medicare, boomers, and healthcare information (broadly construed). We are fast coming upon a true constituency-based phenomenon, the largest, single, and united constituency group the US has ever seen begins this year—those residing in both the Medicare and boomer demographics. Contrast that with the diverse constitutency groups composing the Medicaid demographics coupled with the strong negative stereotypes of Welfare, the poor, the immigrant, the illegal, etc. Funding Medicare will always be more politically acceptable over funding Medicaid. Granted the states are not responsible for Medicare funding, but they are responsible for the state and locally employed boomers (and dependents) that will be retiring and utilizing their state/locally funded healthcare.
In California, the Medi-Cal receipents have been placed into managed care Medi-Cal programs that at least in my area (Sacramento) has had four major problems. First, managed care has driven so many providers out of the area there exists long waiting times for any forms of health services. This creates a collateral pressure on the ERs—”managed Medi-Cal” just can’t be seen in a timely manner. Second, because of the inability for them to be seen in a timely manner their health problems are more complicated and more advanced—which snowballs even more ER utilizations.
Third, those not able to get into the managed Medi-Cal programs are pretty much disenfranchised from all providers, because almost all providers are aligned with existing managed plans—there are very few providers that will pickup “straight Medi-Cal.” This constitutes another collaterally pressured group of Medi-Cal receipents into the ERs.
Fourth, a catagory of Medi-Cal called “emergency Medi-Cal,” which was created to provide Medi-Cal coverage for emergency conditions. Whether intentional or not, it is widely perceived that “emergency Medi-Cal” is not for “emergency” as a condition but for “emergency” as a venue. The ER becomes the venue for all Medi-Cal services under this misinterpretation. A very typical dialog with members in this category of Medi-Cal starts with “I have my emergency Medi-Cal and I want….”
What would be the effect of limiting Medi-Cal funding in California—immediate proportional and incremental increases in ER volumes for true emergent needs, for those further disenfranchised from primary care providers, and for those that already believe “the system owes them.” For good and bad reasons, Medicaid programs have incentivized behaviors and expectations over time. Changes in “who is covered” and “what is covered” without credible alternatives and potent counter-incentives will just drive-up ER utilizations.
There is a profound misunderstanding in the US about “Emergency Room,” it is an oxymoron, because utilization of the ER for everything other than a true emergency has been pervasively incentivized.† We have created a near-entitlement in the form of Medicaid and we have created a general expectation that any medical condition may be addressed in an ER.
† Aside, when I first started my EM practice I was very incensed at parents on Medi-Cal who would bring their febrile child to the ER to get a prescription for APAP and had a pack of cigarettes sticking out of their shirt-pocket or purse. Over the years, I’ve come to have two reflections on the matter, first, I can’t affect social and healthcare policy in the ER at 3 AM (the hair trying to wag the tail that wags the dog); and second, not writing the prescription only causes the child to suffer.
Glogging while the cat’s away…
First, I’ve got to get use to the Movable Type interface again—I haven’t used a WYSIWYG editor since my blogging infancy, circa 4.04. I have the same version over at symtym, but it is just for looking at the “nuts and bolts.” So turn off the WYSIWYG editor and use my much preferred AR markup in XHTML.
Second, I try to collect EM relevant abbreviations/phrases/terms—we have a vast wealth of colloquialisms with bad pronunciation, grammar and spelling mixed in. Humor is always a good place to start this “guesting” relationship. Old favorites and a few new ones in no particular order, with commentary (of course):
Enough of that PC stuff…
Third, Press Ganey revving the engine while in park.
The average length of stay in U.S. emergency rooms is 3.7 hours, or 222 minutes. The state-by-state look at emergency department waiting times was conducted by Press Ganey Associates, which measures patient satisfaction for 35% of the nation’s hospitals.
The report on emergency-room times is based on about 1.5 million patient questionnaires filled out in 2005. And it shows wide state-to-state variations in the time between entering the hospital’s emergency department and being admitted or sent home.
Iowa (138.3 minutes) and Nebraska (146.1 minutes) had the shortest emergency-room stays, while Maryland (246.9 minutes), and Arizona (297.3 minutes) had the longest.
Press Ganey measures the perception of performance (subjective), which is the surrogate for actual performance (objective, if all biases can be truly identified and controlled) and even farther removed from production. If we desire the countries EDs to function like public safety (which is often the expectation)—then they must have a production model akin to public safety. There are worlds of differences between an average response and a percentile response. Take a typical marking ploy for hospitals, stating an average door-to-doctor time in the ER that averages 30 minutes, 50% will see the doctor in greater than 30 minutes (normal distribution). Contrast that with a paramedic ambulance provider that has a contractual requirement to provide an ambulance to the scene within 8 minutes 90% of the time (normal curve skewed markedly to the left). Such a degree of production (moving the whole curve to the left on the time axis) requires tremendous additional cost and infrastructure. Skewing the production to the left (moving the “hump”) will require even more cost and infrastructure. Anyone involved in a high performance EMS systems knows that all components must be at peaking staffing—i.e., to wax biochemical, we’re dealing with zero-order reactions, where production is constant and continuous. This can be achieved in EMS with 90% reliability, but healthcare and the payers have no such commitment or public mandate.
Press Ganey gets to rev the engine—and gets paid very well for doing it. It has very little to do with quality or the offering of credible solutions, but everything to do with the promotion of competition amongst healthcare entities.