Sunday, February 7, 2016

Are High-deductible Health Plans Working?

May I whine for a few sentences please?  My staff and I have a high-deductible medical insurance plan.  As the costs of coverage increased each year, we had to find a product that we could afford for our small private practice.  As any small business owner knows, margins are tight, revenue is declining and expenses inexorably rise.  And physicians, unlike other retailers, cannot raise our fees.  Would you want to invest in a company with this business model?  If so, then contact me directly.

High-deductibles health plans are painful for consumers.  The first several thousand dollars are borne by the individual.  While we have an HSA (Health Savings Account), which confers a tax advantage, it is still painful to fork over wads of one's wages to cover medical expenses.  Isn’t that what medical insurance is supposed to do?

Would we expect fire insurance to cover only part of our house if it burned down?

Will fire insurance cover a fire?

But, I recognize that high-deductible health plans are an effective means to combat over-diagnosis and over-treatment, two of the deepest systemic failings in the medical profession.  Indeed, highlighting these two practices has been a leitmotif of this blog.  I have repeated in multiple posts my belief that patients need to have skin in the game if cost-effective medicine is to be achieved.
Just this past week I have seen how this works.

A close acquaintance has been suffering from arm pain and consulted an orthopedist.  A steroid injection was administered and the situation fortunately improved.  The individual contacted the physician’s office for additional advice and an MRI of the arm was advised.  The patient replied that she would research area radiology facilities for pricing as this service would be out-of-pocket as she had a high deductible plan.  Later, on reflection, the individual decided to hold off on the MRI, particularly as she was improving.

There’s a lot we can learn in this vignette.
  • It’s easy for physicians to order tests that cost them nothing.
  • It’s easy for patients to accept tests that cost them nothing.
I’m sure that if my acquaintance had full coverage with no deductible, that she would have dutifully accepted the advice for an MRI.  Why not?  The doctor wants the test and it’s free.  However, if this patient has to shell out a thousand bucks to view the internal workings of an ailing arm that’s making progress, there may be some push back.  My personal belief is that this MRI was not only expensive, but was not medically necessary, a terrible combination that is responsible for so much rot in our health care system.
Of course, I realize the dangers of high-deductible plans.  Indeed, many previously uninsured folks who have been ‘rescued’ by Obamacare are now facing this predicament.  Many of them forfeit medical care that they and their families need because they can’t afford it.  For so many families, a $5,000 deductible is like not having medical insurance at all. This has to be fixed, and it won’t be easy. 

Let me share an arcane law of economics.   It’s easier to spend someone else’s money.  Consider this example.  When you are in a fancy restaurant, and someone else is paying, do you order differently?

Sunday, January 31, 2016

Can Physicians Take Vacation?

Years ago, I was having dinner with 2 members of The Cleveland Orchestra, one of the finest orchestras in the world.  I asked them, with my kids present, how much time they devoted to their craft.  As many parents know, getting kids to commit to practicing a musical instrument is about as easy as splitting the atom.  The musicians told us how much time they practiced, which was mind boggling.  Any artist or athlete or Green Beret or similar professional, has to demonstrate extraordinary commitment to maintain a superlative level of excellence and preparedness. every day.

I asked one of the musicians, the violinist, how long he could stay away from playing his instrument before he noted some professional slippage.  Guess your answer.   At the end of this post, I will relate his reply.

How long can you be away from your job before your performance ebbs?

For most of us, we can take weeks or longer on holiday and return back to our positions seamlessly. 

A few examples.
  • Politicians return to Congress after long breaks and lose not a whit of their skills of obfuscation and duplicity.
  • New York City cab drivers return from vacation and can make their first passenger’s heart stop without missing a beat.
  • An airline customer service representative a few continents away maintains state-of-the-art client service even after a month away from her cubicle.
What about doctors?  What about gastroenterologists?

Yes, I do take vacations, but most of them are long weekends.  I took 5 days off in a row last August.  Now that my kids are grown, I have taken a few longer vacations, but during the most of hte past 2 decades, my times away from home have been brief outings.   Perhaps, the reason why I maintain such a keen colonoscopy edge is because my absences have been brief.  If I took a sabbatical for 6 months, would I be rusty when I approached my first rectum on my return? 

Medicine - Like Riding a Bicycle

I will admit that manipulating a colonoscope, when I bring light into a dark world, is not exactly the same as playing a violin in the Cleveland orchestra.  I’ll leave it to the reader to contemplate which of these takes more skill. 

Seriously, do physicians lose their cognitive and procedural skills after a period of time?  I’m not sure this has been tested, but I believe the question is a reasonable one for patients to consider.  Hospitals track volume of surgeries from specific surgeons, but a busy surgeon could meet the yearly threshold, which might be modest, and still take several months off.  Should a patient who is to undergo a cardiac bypass or a colonoscopy after the physician has been away for a few months be concerned? 

Is medicine like riding a bicycle that one can do well after a hiatus of years or more?  Or should doctors who have been off the bike for a while put some training wheels back on?  

Consider this the next time you are hearing music from a master musician.    One thing is for certain.  (S)he hasn’t been on the beach.   The violinist I queried told me that he if doesn't practice for 3 days that he is below par.  Would you like to have a job like this?

Sunday, January 24, 2016

Free WiFi in the Doctor's Office?

I am always always been irked when a hotel charges me for Wi-Fi use. This pick-pocketing is resented by hotel guests across the fruited plain.   This money grab is taken right out of the airlines’ playbook, who now charge us for carry-on bags, an aisle seat, a candy bar, a working flotation device ‘in the unlikely event of a water landing’ or a functioning oxygen mask.   Need to change your reservation?  Easily done for $150.  On what basis can this fee be deemed reasonable?  It constitutes consumer abuse of the first order.  Although airline profits are soaring, and fuel costs have tanked, there has been no trickle-down effect to travelers, who are left with little recourse except to pen cranky blog posts. 

Airlines Heading Back to No Frills

Hotels know that Wi-Fi is like oxygen.  Since we can’t live without it, why not extort a few dollars for it.  A paradox in this exploitative practice is that cheap hotels give their guests free Wi-Fi, while top tier hotels might charge $15 a day for the privilege of using a service that costs the hotel nothing.  There will usually be some inconvenient location where it is free for all, knowing that most of us want the service in our hotel rooms.

“We have a free Wi-Fi area on the other side of the parking lot.  Since it’s raining, we do have umbrellas available, for a small fee…”

Guests are pushing back.  Hotels are taking notice and backing off.  We have an expectation that some goods and services should be free according to natural law.

Here are some items that I never want to pay for.
  • Water at restaurant
  • Bread at a restaurant
  • WiFi
  • Customer service from a living, breathing human being regarding a product I have purchased.
  • An extended warrantee.
  • Plastic or paper bags at a supermarket.
  • Parking lot fee at a theater. 
  • Shipping and handling fees. 
The medical profession is always on the lookout for revenue enhancement.  Perhaps, we should also adopt an a la carte fee approach.  Here are some items we might start charging for in our gastroenterology practice.
  • Pre-visit handwash.
  • Restroom use.
  • Toilet paper in the restroom.
  • Working light in the restroom.
  • Clean colonoscopy equipment.
  • Waiting room magazines less than 6 months old.
  • Waiting room chair use.  This would be coin operated.   Once the 15 minutes expires, the patient would have 2 minutes to insert additional coins in order to avoid a very gentle series of electric shocks.
Why should we physicians leave money on the table?  If you want to change your appointment, we can do this for a mere $150. 

Perhaps, our practice should establish a Rewards Program, where patients can accrue points after each office visit.  100 points might give you a preferred parking place.  250 points might guarantee you an on time appointment.  500 points might entitle you to extra anesthesia during your procedure.  And, 750 points might grant you a half hour access to our Wi-Fi. 

Sunday, January 17, 2016

Should Patients Consult Dr. Google?

You see your gastroenterologist with long standing stomach pain.  You have undergone a reasonable evaluation and all the endoscopic bodily invasions and imaging studies of your abdomen have been normal.  Repeated lab work provides no clue explaining your distress.   You have been twice to the emergency room and were sent home with  prescriptions that didn’t work.  You are frustrated and so is your gastro guy.  You are convinced that there is a diagnosis that has been missed and you have the Google search to prove it.

Every physician has had patients who come into the office with reams of paper from an internet search.  Usually, this approach uses a net that is just slightly over-sized for the task at hand.  It would be like using a butterfly net to catch a paramecium.

Paramecia - Use a Small Net to Catch these Critters!

Plug a few symptoms into a search engine, and then be prepared to take a year or so to review the results.  Pick a symptom, any symptom.

Whistleblower Search Suggestions
  • Causes of stomach pain
  • Causes of fatigue
  • Causes of fever
  • Causes of joint pains
  • Causes of dizziness
The above searches might crash your computer and I hope I will not be legally vulnerable should this occur.  

The internet is a powerful medical tool.  Most physicians, including me, rely upon it.  It contains an encyclopedic reference on all knowledge, but hasn’t yet been able to rival living, breathing human healers with respect to medical judgment.  Of course, artificial intelligence will surely enter the medical arena in our own lifetimes.  Technology will continue to byte into the medical profession bringing great rewards and many costs to society.  While we can argue over technology's merits and drawbacks, its victory is inevitable. 

I counsel patients daily that we physicians cannot eliminate all diagnostic doubt.  There is no CAT scan, laboratory study, physical exam or professional opinion that is 100% certain of anything.  All of us want reassurance that we are well.  Every physician has been asked throughout his career by worried patients, “are you sure I don’t have cancer?”  Seasoned physicians are very careful with our speech and choose words carefully.  We rarely speak in absolute terms.

We can’t exclude every diagnosis, but like lawyers, we strive to surpass a reasonable doubt threshold.   How much uncertainty are you willing to accept?  How much doubt will your doctor tolerate?

Of course, this varies with the circumstance.  We are likely to push harder to explain rectal bleeding and weight loss in a 60-year-old man than we would in an 18-year-old college freshman with stomach aches. 

The hypothetical patient at the beginning of this post wants more work done.  Assume the physician has already excluded 85% of the common causes of stomach pain.   How much more medical work and money is worth reach the 90% level?  95%?  If we use the patient’s Google search as a road map, then the diagnostic journey is likely to be an endless excursion into the abyss. 

When we  search Google to find a restaurant, a vacation site, a plumber or a movie review, most of us well click on a few hits, even though there may be hundreds or thousands of search results.  We can’t spend our lives swirling and spinning in a search engine, even if it means we did not hire the best plumber.  We make a reasonable effort and then we make a decision.

While I admit that the stakes are higher with one’s health than with a clogged toilet, patients need to be wary of an avalanche of medical information that spews forth unfiltered noise and static. 

I’m not suggesting that if you have an unexplained symptom that you simply accept it.  Of course, one reason your symptom might be unexplained is because a diagnosis has been missed. There is a role for a second opinion or pursuing additional medical studies.  But, not every symptom can or should be explained.  Every case is different.  Knowing when to pull the trigger or to hold your fire – the essence of medical judgment– is not something I would consult Dr. Google on.  I'd talk to a real doctor instead.

If you feel I've missed the mark on this post, go for a second opinion.  Google is just a click away.

Sunday, January 10, 2016

Why My Patient Left the Office

A patient came to the office and refused to see me, although I was quite willing to see him.  I’ll present the scenario followed by the patient’s reason he took an abrupt U-turn.   Then, if you are inclined, you may offer your own advice and comment.

I performed a colonoscopy on this patient and found a large polyp in the upper part of the large intestine, or colon.  The upper part of the colon, or right side of the colon, has been receiving a lot of press in gastroenterology in recent years.  Medical studies have observed that cancers in this region are more easily missed for reasons that don’t need to be explained here.  For this reason, gastroenterologists are particularly vigilant when examining this region.

The polyp was large and somewhat hidden behind a fold of tissue.  I suspected that this was a benign lesion.  I removed the polyp using one of the gadgets in our bag of tricks, but knew at the time that I had left some polyp tissue behind.  I was unable to remove the entire lesion because of its tricky location.  In addition, because the polyp seemed to be embedded in the wall of the colon, I wasn’t certain that I could safely remove the remaining fragment without causing a complication.  First, do no harm.

The Large Intestine - Where Polyps Hang Out

I advised the patient to return to the office in 3 weeks so that we could review the options.   In the meantime, the pathology report from the specimens confirmed that the polyp was benign, but pre-cancerous.  The remaining polyp tissue would have to be removed.   Our practice has a No Polyp Left Behind policy.

There are 2 options that make sense.
  • Have a surgeon remove the R side of the colon, which would guarantee safe and complete removal of residual polyp in one session.
  • Refer the patient to an expert colonoscopist at one of our nearby teaching institutions.  There are advanced techniques and skills that could complete the task that I left unfinished without surgery.  This is certainly easier to go through than an operation, but there is a lower probability that all of the polyp will be removed in one session.  Therefore, future colonoscopies would be needed to reexamine the site to verify that it is clean.  Colonoscopies have risk and inconvenience.   This approach, in my view, affects quality of life as for a long period of time, the patient has concern about polyp tissue left behind.

Discussing these two options, with their respective risks and benefits, is a long conversation.  I would anticipate many questions from the patient and any family member who might be present.

The patient came to the office at the appointed time, but then balked when he was asked for his $40 co-payment, as required by his insurance company.   Of course, we have nothing to do with setting co-payment rates.  While I have respect for the sum of $40, I think it can be argued that this is not excessive for receiving a full presentation of medical options from a physician on how best this patient can prevent colon cancer from developing.    

He left the office.  How should I react?  Should I call him and provide a ‘free office visit’ on the phone for 15 minutes so he doesn’t have to fork over the forty?   I make dozens of phone calls to patients every week, but these are generally to resolve simple issues.  If during one of these calls, I decide that a phone call is not appropriate for resolving the issue, then I ask the patient to make an appointment.   While a patient might think, for example, that I can diagnose and treat diverticulitis on the phone, I prefer a hands on approach here.

Should I write to my PPP (petulant polyp patient) and advise him that he needs to see me face to face as the issue is more than a phone call can handle?  What if I do so and he doesn’t show up.   If a few years from now, the lesion turns malignant, then will this be my fault?  When does my responsibility end and his begins?  

Sunday, January 3, 2016

Whistleblower Looks Ahead to 2016

At the end of every year, the airwaves compete for our attention on programming that ‘looks back’ at the past year. 

People we’ve lost in 2015.
The 10 biggest news stories of 2015.
The greatest gaffes of the past year.
Stories that made us cry in 2015.

Year-end magazine issues follow the same playbook.

Whistleblower doesn’t look back.  

Whistleblower Eschews Rear-view Mirror

I suppose there is a public appetite for retrospectovision since, as we all know, the media’s mission is to serve up what we demand.  The newspaper adage, ‘if it bleeds, it leads’, is more a comment on us than it is on the journalism profession.  We are vampires who look to media for our next blood meal.

Looking ahead is tougher since it’s quite a bit easier to chronicle known facts than it is to predict and guess.  But, isn’t this a more worthy task?  How do these story proposals grab you?

People we’ll lose in 2016.  (Not serious, just want to assure you’re paying attention.)
Why CNN will abandon the omnipresent banner –BREAKING NEWS – in 2016.
Hillary Clinton pledges no e-mailing in 2016.  Will rely upon carrier pigeons for all classified  communications.
Obama announces bold new ISIS 2016 strategy.  Will no longer ‘contain’, but will now ‘restrain’ the jihadist group.
U.S. Airlines announce new 2016 policy to serve customers better.  While the commodious seats have already been narrowed with the pitch reduced (this means just try to lean your chair back), economy seats will now be upholstered with carpet tacks with the pointy ends facing upwards poised to pierce travelers’ posteriors.  Leaving aside questions of hygiene, by industrial engineers have designed these barbs so they will not cause significant blood loss, unless there is air turbulence, which would be God's fault.  Why are they doing this?  This comports to their philosophy of only charging customers for what they want.  For example, if a traveler does not want enough legroom to accommodate the average sized legs of a 6-year-old child, then why should he pay for it?  Similarly, focus group testing has demonstrated that some passengers enjoy the carpet tack experience.  For them, there will be no surcharge.  Why should these thick skinned travelers have to pay for an upgrade that they do not want?  Any traveler who wishes to pay for a smooth seat, is free to do so.  In line with their reasonable pricing policies, the upgrade costs $35 if requested when your ticket is booked, $75 at the gate and $150 when you reach your seat.

Safe travels to all.  Wishing you all the best in the coming year.

Sunday, December 27, 2015

Why Trump is Running

What is politics without a conspiracy?  Here are two facts.
  • Donald Trump is a very intelligent man. (Just ask Vladimir Putin.)
  • Donald Trump says idiotic stuff.
How does one reconcile these two facts?

When a really smart person says really dumb stuff, then something is up.
Why does he regularly issue forth insulting invective and false statements?

Does he truly believe that John McCain is not a war hero?  Does he feel that schoolyard insults against fellow candidates gives him presidential luster?  Is his plan to slam the door on all Muslims a surefire way to make friends and make us safer?  Is mocking a disabled journalist politically savvy? Is describing Hillary Clinton’s urological delay at the recent debate as 'disgusting', a demonstration of his measured temperament? 

Star Quality?

It’s very tough to ascribe such views to an intelligent man, which he is, and often says so.  Who benefits from his volcanic eruptions of rhetorical venom?  Here are the two winners.

Donald Trump.   He is becoming the most famous man in the world.
Hillary Clinton.   For HRC, he’s the gift that keeps on giving.  She prays daily that he will become the GOP nominee.

Is it possible that his campaign was secretly designed and executed to help Hillary gain the White House?  Did Trump and Hillary make a corrupt bargain?  Is this really implausible when you take an aerial view of events?  Is this hypothesis more far-fetched than your own explanation of Trump’s strategy and tactics?

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