Random Thoughts from a Restless Mind

…well, you know.

It finally happened; I have finally made decisions that were based primarily on covering my own  ass.  One of these decisions was strategic, and the other one was directly related to the care of one particular patient. Let me explain.

The first decision, the strategic decision, had to do with performing consultations in the hospital setting. These have never been a whole lot of fun, and they have never been a terribly profitable venture from a business standpoint. But for many years I, and most other off ophthalmologists in my community, have performed hospital consultations at the request of both community primary care physicians and hospitalists, pretty much whenever we were asked. Almost none of these consultations was mandatory, an examination that absolutely had to occur during the time of hospitalization. Oddly enough, or perhaps not so oddly, a significant percentage of the patients for whom these consultations were performed were uninsured, way more than the likelihood of this occurring due to chance.

That was okay, though, for the longest of times. Everybody was doing it, performing these consultations, and those of us who did so received a kind of “good Samaritan” benefit of the doubt. You see, we do such extraordinarily good work as a specialty, and that work is so terribly dependent on very advanced technology including large, expensive, and mobile equipment, that every consultation that we performed in the hospital setting was a pale, inferior product in comparison to a consultation performed in our offices. As time has gone on my sense that I would continue to receive this “good Samaritan” dispensation has disappeared. I have  come to feel more and more vulnerable, more and more concerned that the inherent deficiencies of the hospital consultation in  ophthalmology make it more likely that I will miss something important despite my best efforts.

And so I am now declining to  accept hospital consultations except when I am obligated to do so as part of my turn covering the emergency room.

Now, you could accuse me of being selfish, of using everything above as a simple rationalization to stop doing something that is inconvenient and unprofitable. It’s ALWAYS been inconvenient and unprofitable! What has changed is that it now feels more dangerous to ME.

I’ve struggled with this decision, frankly. In the end, though, the decision to stop doing consultations in the hospital was actually rather easy because the quality of care that I was able to provide in that setting was so dramatically inferior to the quality of care that I have been able to provide in my offices. It was a different event, a different decision made in the context of caring for one, individual patient that has brought home just how pervasive this climate of fear in which all physicians live has become. Faced with the decision that hinged on my safety versus the convenience and care experience of one of my patients, THIS time I chose my own safety, and I made the decision in a nanosecond.

My patient was scheduled for cataract surgery on her left eye. During her prep in the pre-op holding area it became clear right away that she had prepared at home for surgery on her right eye, putting her preoperative eyedrops in the wrong eye despite our verbal and written instructions to the contrary. What  should we do, the nurses asked? Easy answer: cancel the case. But her son had to take off work, and another family member took off work to stay home with her this afternoon. Easy answer: cancel the case.

It wasn’t always this way. Years ago, in the early 90s, a patient prepped the wrong eye for glaucoma surgery. Knowing that I was planning on doing both eyes eventually I simply changed course, changed all the paperwork, and went ahead and did the eye that she had prepped. Things are different now, though. There is a paper thin line between “other eye” surgery and “wrong eye surgery”. Wrong eye surgery is a “never event”, one of those things that is simply inexcusable, and one of those things that various and sundry watchdogs are looking to find. Take a chance on some overzealous, faceless, nameless functionary, perhaps someone who has never been involved in the surgical process confusing “other eye” surgery with “wrong eye. surgery? Not a chance…cancel the case.

And that was that. For the first time in my career I had put my own ass ahead of the convenience and experience of my patient. I willingly and knowingly inconvenienced by patient and her family, even though the eventual plan was to remove both of her cataracts, because I was afraid to change the surgical plan at the last minute. Afraid that some red flag would be raised because I had changed the surgical site. Afraid to expose myself to those overzealous, nameless, faceless functionaries.

I covered my own ass!

Again, one could accuse me of being self-serving, self-righteous even. This was the first time that I had ever knowingly made this kind of decision, and frankly I can’t even remember a time when I made a similar decision for a similar reason. What was so extraordinary was how instantly I came to this conclusion, how quickly the words “cancel the case” came out of my mouth, and how completely comfortable I am with the decision. Me, the champion of patient-centered medicine, borderline obsessed with the crusade to bring the best customer – centered practices from the best consumer service industries to medical care. I instantly and knowingly put my own self protection ahead of the convenience and experience of my patient and her family.

To be honest, both the patient and her son were very understanding, and she has gone on to have very successful cataract surgery on the correct eye. No harm no foul, as the basketball great Bill Russell would put it. But that’s not really true, is it? An entire system is set up in such a way that my decision has become the  ONLY viable decision. Only the foolhardy, the reckless, or the naïve would do anything else. It’s a non-choice anymore. We physicians, descendents of those who willingly and knowingly walked among lepers and ENTERED plague-infested cities, fearless in our professional service, we have finally met our match. Terrified by those nameless, faceless, functionaries, cowed by those most definitely named, whose pictures grace the covers of our phone books, we are now left with but one  course of action.

Physician, cover thine own ass.

I got a bill the other day for care that was provided to a member of my family. The care was provided at one of the huge behemoths here in Cleveland. Now, this was just an office visit, not anything exotic like a fancy test or some new surgical procedure. And yet, there it was, at the bottom of the billing statement: “facility charge”. I knew it would be there, but still seeing it made me chuckle. “Facility charge.” What a great gig! Not only do you get to charge for the professional services provided, but you get to put a separate fee to cover your overhead on the bill! Dude, where can I sign up?

Well, that’s just the point. I CAN’T sign up for that cruise. You see, I’m a physician in private practice. You know, old-time medicine. The doctor owns his own business, pays the rent, makes payroll every two weeks. If something breaks he or she writes a check. Exactly like the pediatrician when you were a kid who gave you that scratch on your shoulder when it was time for your polio vaccination. No “facility charge” associated with that visit! Nope, Just a few dollars passing between your mom and the lady manning the front desk. You never really thought about what happened to those few dollars, of course. Heck, you were only seven! Your mom never really thought about it either.

Until recently the vast  majority of medical care provided in the United States, at least care that came from physicians, was provided at the hands of private practitioners like me and like that pediatrician you saw with your snotty nose as a kid. Contrary to the wishes of countless faceless bureaucrats in Washington, a significant percentage of care continues to be provided in exactly the same way. Even in very large, institutional medical groups a “facility charge” is nothing but a happy fantasy. The money that your insurance company pays to your doctor does NOT go into your doctor’s checking account until all of the bills are paid

This is why the proposed 21% cut in physician’s fees for the care of Medicare patients is so much bigger than even 21%. This is also why it’s so difficult for patients who are covered by Medicaid to find a doctor. The notion that somehow increasing the Medicaid rolls, taking people off of the uninsured list and placing them on the bigger list of people whose medical care might be covered by Medicaid, is such a farce. People who have Medicaid now have enormous difficulties getting access to the care that they need. What makes those same faceless bureaucrats think that they have made any headway increasing access to medical care by putting more people on Medicaid? Doctors and most hospitals avoid seeing patients on Medicaid, just as they will avoid seeing patients on Medicare if that 21% cut goes through, because they DON’T GET PAID.

Well, how about technology? Is it possible to increase the efficiency of doctors working in their offices with the use of new technology? Efficiency, yes. Efficiency while making sure that our doctors get paid, no.A USA Today article looking at the daily workload of primary care doctors found an average of 55 services performed each day in a 4  doctor group that went unpaid. Services like answering phone calls and refilling prescriptions, reviewing lab reports or consultation reports, or interacting with patients by e-mail.  On the face of it,  increased access to your doctor through alternate venues, something different than coming in to the office where the bricks and mortar have to be paid for makes sense. It makes sense, that is, if the doctor gets paid for it!

Why should you care if your doctor gets paid? I mean, didn’t President Obama point out how much pediatricians get paid for taking out a  patient’s tonsils (read that carefully)? Wasn’t it some huge number that made no sense? Aren’t we supposed to be moving toward a system where doctors are paid a salary, where there’s no incentive to order extra tests or do extra procedures since we know that doctors are incapable of separating their own economic interest from the best interests of the patients in 2010? You know, like World Class Hospital, repeatedly beatified by both the President and those same nameless, faceless bureaucrats in Washington, held aloft as the shining beacon of hope, the one true path to higher quality care at lower cost.

Funny, that. The World Class Hospital is actually an extremely good example of both the best and the worst of where healthcare economics has been and where it might yet go. The World Class Hospital is enormously successful financially because it has mastered the arcane business of doing as much as possible for each patient within the rules of the billing game. There would also be that “facility charge” thing where the bricks and mortar are covered by a surcharge. Although the doctors at the World Class Hospital do indeed work for a “salary”, in many cases that salary is tied directly to not only their own personal production, but also to the amount of money that is generated at the institution as a secondary effect of their labors. Human nature being what it is this produces two very different types of behavior on the part of doctors at the World Class Hospital, and indeed doctors everywhere who are paid like this. While there is still upside, room to do more work and thereby prove that a doctor should be paid more, the doctors are always available. Ready to work. Access to these doctors is rarely a problem.

Unfortunately, the opposite also occurs. Once a certain salary level has been reached many doctors simply slow down. It’s a funny quirk in the system, salaries are rarely if ever decreased. Why work harder if there is neither incentive to do so, nor disincentive not to? The best example I’ve seen recently is a group of general surgeons formerly in private practice who sold their group to the World Class Hospital. This group used to be noted in the community, especially among primary care doctors, for the amazing availability of the surgeons. Whenever a patient needed surgery, or whenever a patient needed a surgical consult, one of these doctors was ALWAYS available. Now? Not so much. 9-to-5, Monday through Friday. Why? Well, they don’t get paid for all of that availability anymore.

It’s a funny thing, money as an incentive. It’s an even funnier thing, how forgetful everyone becomes about money as an incentive when it comes to paying doctors. The mantra from Washington regarding “health care reform” has been the fantasy of better care and greater access at a lower cost. Doctors  to work harder, work longer, and be available to all of us whenever we need them.  We want this as we walk around with “alligator arms”, unable and unwilling to reach for our checkbooks, appalled by a $15.00 co-pay, insulted that there might be some service or care that’s NOT COVERED BY INSURANCE. More and more for less and less… who wouldn’t want that?  I do wonder, though, what the reaction would be if all doctors handed their patient an itemized “bill”   detailing what happens to that egregious $15 co-pay. At last count in our office? Exactly $3.00 to me.

You know, come to think of it, I got paid pretty well in the year 2000. I think I’d be okay with my 2000 salary; you can even keep the 1% pay raise. I’d be willing to work for my year 2000 salary, maybe with a little cost-of-living raise, you know, like the one those nameless, faceless Washington bureaucrats get every year. I’d even be willing to work the way I’ve always worked, available pretty much 24 – 7, 365. How would I do that, you wonder?

Well, let’s talk about that “facility charge”…

She was 89 years old, my last patient, sitting demurely in my exam chair. I think I’ve known her for about 10 years. If I’m remembering correctly we’ve been through two cataract surgeries together, and I’ve done a little bit of laser work for her left eye. In fact, she’s in the office for us to consider some laser for her right eye, but she doesn’t really have any problem with the right eye today. It’s her left eye that’s giving her a little bit of trouble.

“It’s hard to describe. It’s like I have a headache or toothache around my left eye. I don’t have any problem at all with my right eye. I’ve had some sinus problems on this left side. That headachy feeling goes away with a Tylenol and a little bit of warm water. What do you think I should do?”

I look at her chart. I’m starting to remember more about who this extraordinary  woman is. There’s no mention of a family doctor in the chart. “Oh no, all of my doctors have died! All of the department heads and bigwigs I used to see are long dead,” she chuckled. More of her personal history is starting to come to me. 89 years old and she still does the books for her family business. Does all the payroll — files all of the taxes. With the exception of the pain around her left eye the only problem she will admit to is running out of steam in the office earlier in the afternoon then she did a couple years ago.

I start to slip into “Dr. mode” because, well, that’s what I do! That’s what all doctors do. We are presented with a problem, a symptom or disease, and we seek a solution. One of the wonderful things about being ophthalmologist is that I can almost always identify the problem, and once identified I can almost always find a solution. Indeed, I’m kind of intrigued, a little amused even, because this is the very rare time when a sinus problem is actually the cause of eye pain! Just like the majority of my patients with headaches think that the problem is coming from their eyes, so too do most of my patients with pain in the front of their face believe that it always comes from their sinuses. In fact, neither is very true very often. But in this case my patient is actually correct; her pain is referred pain to her eye and her eye socket from sinus problems. We can probably “fix” this, and I start to run through my mental Rolodex of good doctors near her home.

A little bit of unease is setting in, however. My patient is 89 years old, doesn’t have a single medical problem on her problem list, and isn’t taking a single medication. She hasn’t seen a medical doctor since 1978. Her only problem is an ache  around her left eye which she is successfully treating with Tylenol and warm water.

“May I take off my Dr. White hat?  Would it be okay if I talk to you as just Darrell for a few minutes?” A little smile comes at the corners of her mouth and she nods.  Here’s what I said:

“My friend lost his dad last week. By all accounts his dad was a great guy. He led a very active life pretty much through the last day he was alive. Went for a walk. Watched a wrestling practice for one of his grandchildren. Had a big dinner and went to bed with a smile in his face. He never woke up. Your mother  lived to be, what did you say, 104 years old? I think the best chance for you and I to have you leave this world at age 103 like my friend’s dad did last week is if I DON’T give you the name of a doctor to take care of your sinus.

Here’s what will happen if I send you to a medical doctor. Any medical doctor. They will hear you, hear about your pain, and they will do what doctors do. You will get an x-ray and you will get a CAT scan. You will almost certainly get some kind of medicine for your discomfort, medicine that may or may not be any better than Tylenol and a cup of warm water. You’re 89 years old — the doctor will probably find something else “wrong” that needs to be  “fixed”. More medicine… more tests… more time. No one has enough spare time to hang out with doctors! Think of all the wonderful things you have done for more than 30 years in all the time you HAVEN’T spent in doctor’s offices. Do you think you can continue to treat the discomfort in your left eye with Tylenol and warm water? Would that be OK?

Remember, I have my “Darrell”  hat on,  not my “Dr. White” hat. as I’m sitting here talking to you I’m thinking of my grandmother, my beloved Gama. I lost my Gama when she was 86. She broke her hip, went into the hospital, and never made it out. She was really pretty good, not terribly healthy but pretty good, right up until she broke her hip.  She thumbed her nose at all of the well-meaning doctors my Mom tried to bring her to, doing pretty much whatever she pleased right up until the end. Smoked her cigarettes while reading trashy novels…a few beers after supper every night. I’m convinced she wouldn’t have lived a day longer if every little medical problem was identified and “treated”, but I’m sure that her life would have been much less enjoyable if she had received all that care.

Do you think you can handle this discomfort? Would it be okay to continue treating it with an occasional Tylenol and some warm water? (I gently placed a hand on her knee) I really think this is the best thing to do here. I’ll give you the name of MY doctor in case you ever get really sick.”

At the end of the day, whether you are a generalist or a specialist, each of us needs to remember that we care for patients. Entire human beings. Not organs or organ systems, not symptoms or diseases or complexes. We take care of people. Even someone like me, someone who takes care of an organ not much bigger than a large grape. The eye, or the heart, or the left third toe are all connected  to a whole person.

I put my “Dr. White hat” back on. I told her I was available anytime she had a problem, and I looked forward to seeing her again next year. We walked to the front desk together arm in arm.

“Thank you, Darrell.”

That’s what the Cleveland plain dealer and Stephen Koff, Bureau Chief, are with regard to medical malpractice reform — exactly wrong! In a front page article in the March 20 Plain Dealer on tort reform Koff commits the equivalent of journalistic malpractice.  Allow me to explain.

Some time ago I wrote a post explaining my position that medical malpractice tort reform was essentially equal to health-care reform. I wrote a follow-up piece explaining that everyone who is involved in a medical malpractice case ends up losing. In fact, the specter of losing is so onerous that doctors will do pretty much anything in order to avoid a medical malpractice lawsuit. Hence we have the enormous problem of defensive medicine, medical care that is prescribed in order to prevent the filing of a medical malpractice lawsuit, and medical care that does not do anything to improve the health of the patient. There are actually two very distinct forms of medical malpractice tort reform and by confusing and intermingling the two Koff does a disservice to everyone reading his article.

Some 10 or 15 years ago there was a medical malpractice “crisis” where the medical malpractice insurance premiums started to rise so fast and so high that doctors were having difficulty affording them. Premiums rose higher in states that had a more friendly atmosphere for the filing of malpractice lawsuits. In these states many doctors in high-risk specialties like obstetrics and neurosurgery either curtailed their practices, or left the state entirely. Our own state of Ohio was particularly affected by this crisis. Multiple efforts at  “tort reform” were made in Ohio, but it wasn’t until a significant change in the makeup of the Ohio Supreme Court occurred that these reforms took root. Ohio, California, Texas, and other states capped non-economic awards in medical malpractice cases, and this produced a more predictable economic environment for medical malpractice insurance companies. Consequently, medical malpractice insurance rates not only stabilized but began to fall.

Here’s where Koff starts to go astray. Despite the fact that Ohio’s tort reform efforts were specifically directed only at malpractice insurance rates, Koff conflates this with true tort reform that would eliminate nuisance lawsuits. Even though tort reform targeted at stabilizing and decreasing insurance rates would be EXPECTED  to have no effect on medical expenditures, Koff proposes that  the fact that medical insurance costs have risen since 2004 (the year Ohio passed lawsuit liability reform) proves that “tort reform” does not lower the cost of healthcare. This is, of course, nonsense. The medical malpractice tort reform bill passed in Ohio in 2004, similar to all of the tort reform bills passed across the country, was designed and expected only to limit the size of medical malpractice awards in order to stabilize malpractice insurance costs.

Believe it or not, the obfuscation and confusion actually gets worse!. Koff admits that medical malpractice insurance for insurance premiums for doctors have dropped on average 22% since 2006 in Ohio. Success, right? Well, not according to Koff. He goes on to conflate malpractice insurance premiums with family health plan premiums, noting that health plan premiums rose from $9590 in 2004 two $11,425 in 2008. But commercial family health insurance plans aren’t even a good proxy for medical expenses! Numbers, numbers, and more numbers. Let’s just keep throwing numbers in until no one can figure out what number goes in what basket.

Here’s the rub: the type of medical malpractice tort reform necessary to affect the practice of defensive medicine is totally different from the type of medical malpractice tort reform necessary to stabilize and lower malpractice insurance rates. It’s just so painful and so disruptive to a doctor’s practice and doctor’s life to be involved in a medical malpractice case that the only type of reform that will have any effect on defensive medicine is reform that prevents the filing of all but the most clear cases of medical malpractice. There just aren’t enough barriers to the filing of weak cases, or throwing in the names of any doctor whose name appears on the chart of a patient who has suffered some harm while in the medical system. And once you’ve been named in a lawsuit it’s an incredibly time-consuming and expensive process, even if you are subsequently dropped from the case long before it ever goes to trial.

So what are we to do? Well first let’s make sure that we are talking about the right type of tort reform. Tort reform that makes it very difficult to file nuisance lawsuits, lawsuits that have very little chance of succeeding, or lawsuits that have no support from independent experts is where we need to start. Removing the “wild card” aspect of jury trials where a defendant doctor is at the mercy of 12 men and women who are (quite humanly) more sympathetic to the plight of an injured patient than they are to the word of the law is where we would go next. How about the creation of a “compensation pool” to provide for the care of all injured patients whether or not true malpractice has occurred? This would remove the stigma of malpractice or “bad medicine” from what is otherwise simply an adverse outcome, and this would still leave open the possibility of further action in the case of true malpractice.

Let’s also do away with the national databank where every case of malpractice that is either settled or found on behalf of the plaintiff or injured patient is recorded. More medical malpractice cases actually go to trial now than before this databank was created because no doctor wants to settle even the smallest of case if it means his or her name will end up on this “black list”. I have made the point several times before that no one, no doctor and no hospital and no health organization, will report errors until the risk of liability for doing so is either reduced or eliminated. We will continue to have the same errors over and over again, causing the same injuries over and over again, until doctors and hospitals feel free to report these errors without fear of retribution or lawsuits. This, and only this, is the type of tort reform that will have an effect on defensive medicine.

How big a deal is defensive medicine? Here, too, we see a willful underestimation of the impact of defensive medicine in Koff’s article. The CBO reports that nationwide liability reform could cut the federal outlay for medical care by $54-$110 billion per year over the next 10 years. However, in response to a request from the American College of surgeons, the RAND Institute found that the MINIMUM  impact of defensive medicine was approximately 10% of all medical expenses per year. That would be 10% of $2 trillion. Minimum. $200 billion per year. Other estimates by healthcare economists have gone as high as 20% per year. Think saving $200 Billion per year might be helpful?

Two types of medical malpractice liability reform confused and conflated, mingled and muddled by Stephen Koff who gets it exactly wrong in the Cleveland Plain Dealer. This article should be embarrassing to the editors of the Plain Dealer if not for the fact that it probably represents their own level of understanding of tort reform, or even worse represents the editorial view of the Plain Dealer. As an educational piece this is such a bad example of reporting and analysis that Stephen Koff probably deserves to be fired.

I’m betting it gets him a raise.

In a recent post I asked for ideas and advice about the difficulty we’ve been having at Skyvision Centers scheduling emergency patients in a way that did not adversely affect the experience enjoyed by scheduled patients. The responses I received demonstrated a deep understanding of consumer service businesses, supply and demand, and classic business theory. Given the superior intellect of the readership of this blog this came as no surprise. That is except for the fact that almost all of the suggestions that I received were unusable because almost all of them assumed a free market for the services offered and received. Nearly everyone suggested that we charge more for ER services, or that as the senior doctor I should personally charge more for services I perform. Essentially none of the people commenting has any understanding of how doctors are paid.

Since I know most of the people who offered their thoughts this surprised me.  It certainly doesn’t help that neither our elected officials nor our esteemed professional leaders seem to be terribly interested in educating the lay public about how money moves around in this $2 Trillion part of our national economy. The fact that our system of “health insurance” actually insulates all of us from the true cost of our care only leads to more confusion. The recent Business Week cover article on the “$618,616 Death” is a good illustration.  Allow me to step into the breech.

Once upon a time doctors came in two varieties: the esteemed physician who visited and cared for the sick in his own town, and the traveling charlatan who rolled into town with promises of health and longevity out of the back of a covered wagon or Model T. The town’s doctor owed his position to a lifetime of selfless service to his neighbors, while the traveling expert made his name through clever marketing.  They had very little in common, these two different types of early doctors. Indeed it was to protect the average citizen from the hucksterism of the traveling “expert” that the original cry came out to license doctors. What they DID have in common, and which neither of them would share with their present day brethren, is that they both were paid directly by their patients. The town doctor might be paid in chickens or eggs (it didn’t matter which came first), and the “doctor on wheels” always insisted on cash, but both were paid face-to-face by their respective patients. A service or product was provided, a fee agreed upon, and payment exchanged.

So what happened? Well, healthcare became free of course! No one pays for their healthcare, at least insofar as they know. Rare is the patient who has any idea about how much their care or their medicine or their hospital stay actually costs. A tiny little throw-away law written in the WWII days of wage-controls that allowed businesses (but not individuals) to provide health insurance as a pre-tax expense (and the willingness of labor unions to negotiate for health benefits instead of wages), followed by the creation of Medicare in the mid-1960’s has combined to insulate most Americans from the cost of their care.

So what does this have to do with how doctors get paid? Well, Medicare started to run out-of-control cost increases in the early 1980’s, starting first with hospital costs. This begat the “alphabetization” of medicine. DRG’s, RBRVS, HMO, PPO–medicine in America got over run by capital letters! In short every insurance “company”, led by Medicare and the federal government, got into the business of paying less for medical care and did so by entering into progressively more exclusive and restrictive contracts with doctors and hospitals. Wanna take care of Aetna patients? Sure. Here are our rates. Take ‘em or leave ‘em. Take away the ability to charge patients for the amount of money not covered by the insurance contract, demand that doctors either opt fully in or fully out of a plan, and tie all of the fees to a politically driven budget (Medicare) and poof! Away goes not only a doctor’s ability to set her fees but also her ability to pass on mandatory cost increases like rent, payroll taxes, and insurance. In comes the era of irrational pricing and willful price ignorance like that seen in the $618,616 death that actually cost something like $250,000.

It’s not market-based, it isn’t capitalism, and it ain’t healthy.

For some 15 years now every single one of your doctors has experienced a decrease in payment for each service they have provided to you. That’s right, despite the dramatic increase in the quality of care in the United States, the dramatic improvements in the comfort and health of our senior citizens, every hip replacement and cardiac bypass and cataract surgery is now paid at a rate that is a fraction of the rate paid in 1990. Total expenses for medical care have gone up only because more medical care is being consumed, NOT because the cost of that care has increased. The only inflation that has occurred in medicine is in the overhead costs borne by your doctors and hospitals. Wages, rent, insurance, licensing fees, payroll taxes…all of these have kept pace with the overall rate of inflation in our economy. Fees have decreased in real dollars, not just  inflation-adjusted dollars.

To be sure some of these fees were too high to begin with, set at a level that reflected pricing anomalies caused by prior government contracting. A good example of this comes from my world of eye surgery. When I finished my residency a cataract surgery typically cost somewhere in the range of $2200, clearly too high given any reasonable market evaluation. We now do cataract surgery that gets better outcomes with a nearly 0% significant complication rate done more quickly and with a better patient experience. Today’s fee? $649. Pretty good value, that, seeing how it also includes 3 months of postop care. Doesn’t matter if the surgeon is a nationally recognized superstar or the kid who barely scraped by to graduate from his residency, $649. When you take into account the overhead structure of an eye surgeon’s practice, time spent training, risk accepted, and constant seeking of better technique and technology the fair-market trading value is probably closer to $1100 or $1200 per case.

So what’s coming? Well, as I type this the U.S. House of Representatives and the Senate are getting ready to usher in a new era of politically driven price controls. Will these so-called “reforms” lead to lower costs to the system? That surely seems to be the intent. Will this new system of healthcare produce the same degree and scope of breakthrough treatments that we’ve seen over the last 40 years? Will we still see so many of our best and brightest entering the field of medicine, and will our best doctors stay in the game? A tiny article buried in the middle of the Cleveland Plain Dealer might be the sentinel. It seems that between 1997 and 2007 the number of hours worked per week by American doctors decreased by 7.2%, a figure propped up by older doctors who have continued to work 60+ hours each week. Overall doctor fees have decreased 25% between 1995 and 2006, and the authors of the JAMA article quoted note that doctors today “may have less incentive to work.”

Gramp was right. There ain’t no such thing as a free lunch. In the end, as always, we’ll get what we pay for.

We have an interesting problem a Skyvision Centers, one that we have all anticipated with a combination of longing and fear. We are about to become too busy to see emergency visits.

Let me back up a little bit and explain why the entire Skyvision crew is experiencing agita over this before it becomes some version of reality. Skyvision is that rare entity that continues to try to be exactly what it professes to be. In our case, while not unique, Skyvision is a rare example of true patient-centered medicine. You can read about our story here http://skyvisioncenters.com/blog/?p=108. I’ve also been very frank about how I feel about the mega-trends in medicine, trends that is seems will be magnified and accelerated in the coming “Healthcare Reform”. http://skyvisioncenters.com/blog/?p=145. None of these current fads or trends are terribly helpful blueprints for the solution to our new “problem” at Skyvision.

The ultimate consumer service industry is healthcare. Oddly enough, I wrote something about that: “The Ultimate Consumer Service Business” http://skyvisioncenters.com/blog/?p=56 (I’m clearly not above self-promotion here!). Everyone at Skyvision Centers is  on board with that concept. We’ve all quaffed the same Kool-Aid as it were. That’s how we have come to the conclusion that we are about to run out of time to see patients with an emergency, at least in the patient- centered way in which we have done so in our first 5 years. For you see, we have allowed our patients to define what it is that constitutes an emergency FOR THEM; we have not imposed any internal definition of “emergency” on our patients, and we have responded to every single patient-defined emergency with the same response: “come right in.” We have also evaluated and responded to every “oh by the way” additional problem that our patients brought up in the exam room but forgot to mention on the phone when they scheduled an appointment.

So how do we know that it’s a problem now, or about to become a problem really soon? Well, we still measure and evaluate all kinds of metrics that relate to the customer experience in the office. Some of those metrics are really kind of objective, like time and volume and such, and they lend themselves pretty easily to trend analysis. We know, for instance, that our average patient volume is dramatically up, especially over the last 6 months. We also know that the average time that a patient spends in the office for our core service has increased by 6 minutes over the last year, and that one of the internal intervals–how long it takes to be brought into the exam after your paperwork is ready–has increased by 4 minutes. We know that the average number of emergency visits (ER’s) is now 6/day, and that the range is 0-12; there is no meaningful pattern to the ER’s, no actionable mode.

We have been able to handle our ER load in the past because of our dedication to the concept of “process”, our adherence to clinical protocols and flow protocols, aspects of Skyvision Centers that were learned and adopted from the Toyota manufacturing processes. Our internal benchmarks for patient experience were established when we had so few patients and so much time to see them that I found myself telling childhood stories to entertain my patients, lest they feel they were getting the bum’s rush. We find that we have now bumped against the outer limit of “acceptable” by our own standards, standards which place us in the top 1% of patient experience, and must now make capital investments in order to remain there.

It is the ER load that has forced our hand, for it is the ER visits that have pushed us into the “discomfort zone” of longer patient waits and longer patient “transit times”. Without ER visits we would still be have “running times” like 2008 or 2007, even though our schedule volumes are dramatically higher, and we would perhaps be able to make smaller capital and staff investments more slowly. Adding more equipment and more staff is scary, especially in this economy and with all of the uncertainty surrounding Healthcare right now. Skyvision Centers is a business after all, and no one has received a raise in our first five years (indeed, I am still working for what amounts to an 80% pay CUT). Simply throwing more staff and more exam space at the problem isn’t so effective if it bankrupts the business. Kinda tough to provide a wonderful patient experience if the doors are padlocked.

So the question is now how do we handle ER visits? I know of a number of practices, probably the majority in our region, that simply give the ER patient the next available open appointment, whenever that may be, even if it is days or weeks ahead. Should we do that? Still others send patients to a local Emergency Room; it’s an emergency after all. One of our local institutions, widely lauded by DC gobbersnoppers including our President as the bellweather example of all that we should aspire to in healthcare, directs all patient-defined same-day ER visits to the World Class Hospital Emergency Room; even if you are an established patient with an established doctor-patient relationship their triage in the Emergency Room directs you to a doctor-in-training for your ER care. Should we simply “turf” our ER visits like World Class Hospital?

Thus far we have allowed our patients to define an emergency as anything they, the patient, feels is an emergency, and we have seen them right away that same day. Should we take back control of the definition of emergency and perform telephone triage? My staff and I certainly know the difference between emergency, urgency and inconvenience. We can define and ascertain what constitutes severe and what constitutes minor. Should we perform triage and schedule ER visits in open slots on subsequent office days according to long-established standards of severity and then availability? Tough call. A foreign body sensation is a “next couple of days” triage, but have you ever felt like you had something in your eye? It’s maddening. Imagine waiting a couple of days to be seen.

Should we openly state to all of our patients that we will continue to see ER visits as we have always done? Severity defined by the patient and “come on in” our response? In tandem with this will our scheduled patients agree to the implied contract that any increased wait they experience is an “investment” in their own future ER care? That they are agreeing to wait a little longer for their scheduled visit because of the “there, but for the Grace of God” phenomenon, that they, too, will go to the front of the line should an emergency befall them?

We’re all patients; I fear that that we  will all experience this in the near and not so near future, especially if the DC gobbersnoppers get their way with “Healthcare Reform”. We at Skyvision Centers are quite frankly way better at providing an enjoyable patient experience to go along with best in class medical outcomes already, and I fear that we are going to find the going even more lonely as we agonize over issues like this. I don’t see a whole lot of folks on the “service” side or the finance side of this equation spending too very much time thinking about the effect of emergencies in the medical office and how they affect our experiences as a patient, the person receiving the service.So what do you think? You’re a patient. From the patient’s point of view what would YOU have us do?

The suggestion box is right below…

It’s become quite fashionable to call oneself “patient-centered”. It’s rather trendy, in fact. Large, quite famous medical institutions now trumpet their new “patient-centered” care initiatives. The hiring of a “patient experience officer” is front page news in Cleveland. The airwaves are choked with advertisements from doctors and hospitals alike, beaming with pride and anxious for you to know that now it’s “all about you, the patient.”

What it really turns out to be is LIPSTICK ON A PIG.

It’s the same hospital with the same staff and the same processes. The same doctors are in the same offices and get paid the same way. A new paint job and new curtains cannot hide the fact that you wait just as long sitting in the same, old chairs in the same old waiting room. No amount of  advertising or re-branding is going to magically change a 1990 Mercury Sable into a brand-new Mercedes 500SL, and if you close your eye  you still know which one is taking you for a ride.

Since when is “it’s all about the patient” news? Isn’t that the way it’s supposed to be? Do the doctor and the nurse have a job because a patient needs their care, or is the patient there so that the doctor and the nurse can have jobs? How many times have you wondered if that big, beautiful new $100 Million hospital wing is being built to handle all of the patients who must be turned away, or if the hospital will now embark on a campaign to find patients to fill that new, superfluous edifice? Or worse yet, if the $100 Million addition is simply a way to launder all of the “revenue in excess of expenses” generated by the “non-profit” hospital?

Medicine is the ultimate consumer service business. Even more so than any other service business because the people who bring you medical care have been entrusted by a patient to do some version of the next right thing for that patient; they have been trusted to put the care of the patient before their own care and feeding. We do a wonderful job of curing disease in the United States, but we don’t do such a great job of caring for patients, lost as we are in our zeal to care for diseases. Patient-Centered Medicine means looking at the curing of diseases from the patient’s viewpoint rather than the doctors’ or the nurses’ or the hospitals’.

Patient-Centered Medicine is all about the patient’s EXPERIENCE.

Enter Skyvision Centers, a unique take on eyecare built from scratch centered around the patient experience from the ground up. Two eye doctors, an ophthalmologist and an optometrist, left a very successful practice (where very high quality eye disease care is still being offered) to start something new. Something radical. Something truly focused on the patient experience from the very beginning. We had nothing but our names and our reputations. No patient lists. No accounts receivable. Heck, in the beginning we didn’t even have an address! All we had was a blank piece of paper with “Skyvision Centers” written on it, and a picture of a patient in the middle. We built our business around that patient and her experience.

Benchmarks? Sure! We went out and benchmarked Nordstrom’s and the Canyon Ranch Spa and the Ritz Carlton to learn about the best practices in customer service. We studied the mechanics of the Toyota manufacturing methods to learn about flow processes, accuracy, and safety. We built an office that allowed us to maximize our efficiency in a setting that looks and feels more like a boutique hotel or retail setting, with lobbies rather than waiting rooms.

Every staff member went on a customer service “field trip” where we ate lunch at a Holiday Inn and dinner at a Ritz Carlton. We witnessed three of our staff members experience a makeover at the Almay counter at Dillards, and then watched three other staff members ENJOY a makeover at the Bobbi Brown boutique at Nordstrom’s. We checked into a room at the Holiday Inn to have a standard hotel experience, and then checked in and spent a night at the Ritz Carlton. All of us. The non-doctor staff and their spouses stayed on the concierge floor, the docs in regular rooms.

And then we brought it all together and made it Skyvision! Our goal is for each patient who comes through the door to have an experience that is more like the Ritz Carlton than the Holiday Inn. More like Nordstrom’s than Dillard’s. We measure every step of the patient experience and constantly evaluate our customer service just like we evaluate and measure our medical outcomes. We agonize over each sub-par visit or less than stellar service evaluation.

Why? Well, why NOT? Where does it say that providing the best possible medical care with the best possible outcomes has to be coupled with less than the best possible experience? That the most important person in the process is anyone other than the patient? We’ve all seen the check-in process at a Holiday Inn and at a Ritz Carlton. They both work, but they sure feel different, don’t they? Why is it that the majority of check-in processes at medical offices and institutions feels more like a busy airline ticket counter during a storm than the front desk at Canyon Ranch? If the cosmetics cost the same at Dillard’s and Nordstrom’s (you know, like your co-pay for a visit), why is it that you feel so much better after shopping at Nordstrom’s?

We all took a financial bath in the first four years of Skyvision Centers. Hey, starting from scratch is hard! In the end, though, we created what is one of those very rare creatures, a true Patient-Centered Medical practice. It should make you wonder how much better your experience would be if all of those busy practices and all of those hospitals building their new wings took some of the money they are spending telling people that they are “patient-centered” and actually tried to put YOU in the center. We’re pretty much an open book. We’re happy to be the benchmark. Heck, we’ll even go along on their “customer service field trips”! This Patient-Centered Medicine is more fun to provide, too.

But until they do, until all of those folks advertising their all-new, all-you, “Patient-Centered Medicine” spend some time looking at the experience of receiving medical care from the viewpoint of the patient, all of us who are those patients had better pucker up.

The pig just got her make-over.

“What made you want to be an ophthalmologist, Dr. White?”

Not a day goes by that at least one of my patients doesn’t ask me this question. Today it was a new patient, 75 years old or so, and a young man in for his first glasses at age 12. Sometimes it’s “why did you want to become an eye doctor?” I have a quick answer for the office of course, but I thought I’d use this as an opportunity to go back in time and “watch” myself make the decision all over again. It was a good decision then, and it’s been a good decision ever since.

I originally thought I would be an orthopedic surgeon. After all, I’m a washed up, blockhead, brain-damaged ex-football player. Orthopedic surgery just seemed to be a really good fit. I loved my Ortho rotation during my 3rd year rotations at UVM. Loved everything about it. The work, the patients, the clinical problems we encountered. I loved the surgeons–heck, they were all basically ME 10 or 15 years older. Loved it all.

Then I met Peter Linton, Chairman of the Division of Plastic Surgery at UVM, and Peter very quickly became my mentor. He and his wife Pam “adopted” my wife-to-be and me, feeding us and giving us a safe place to bring the problems that arise in a young physician and in a young marriage. And what cool surgery! Putting broken pieces/parts back together. Rebuilding a self-image through a combination of technical skill, vision, and artistry. I was smitten, and Peter lobbied day and night, enthusiastically pushing me to follow his career path.

There were a couple of problems, though, with each of these specialties. In the first place people die, and the broken patients in these two surgical specialties are no exceptions. I struggle with death; always have. How would I handle this? Also, I was deeply in love with my bride-to-be and committed to doing whatever it might take to be the very best husband and eventually father I could be. We talked for hours about the impact of residency on our new family, about the killer hours in Ortho and about the 7-9 YEARS of training that most Plastic Surgeons undergo. I can still remember, as if it was last night: “I love you dearly, but I’m not sure if I can love you 9 years of residency.”

My Dad spent his entire working career in ophthalmic manufacturing, running companies that made all kinds of things associated with eye care and vision. At about this time I took a “flier” on an elective in Ophthalmology to see what the medical part of Dad’s world was like. Two weeks of cataract surgery, glaucoma checks and new glasses for nearsighted kids. I followed this up with rotations visiting the academic programs at Georgetown, Wills in Philadephia, and Pacific in San Francisco. A local surgeon in Burlington took me in for a month and showed me what the real life of an Ophthalmologist felt like. What a cool world! What cool gadgets! High frequency ultrasound to dissolve cataracts. Lasers–all kinds of lasers that did all kinds of cool stuff. This was it!

To top it off the residency programs were a total of 4 years long, and most of the Ophthalmologists I met were home for dinner with their families. Score! Although my choice DID come as somewhat of a surprise to the rest of the faculty. When the residency Match results were published the Chair of the Department of Family Medicine cornered me, a concerned and sympathetic look on her face. “What happened, Darrell? You matched in Ophthalmology?” To which I replied “I know, Marga, isn’t it great?” “Hmm…we were all sure that you would be an Orthopedic Surgeon; you were just the right amount of malignant!”

Well, Marga, this Ophthalmology thing has turned out pretty well for me so far. I married that girl, My Beautiful Bride and Better 95%, and we are married to this day. I’ve been home for dinner most nights with her and the kids since then. For the most part my patients don’t die, at least not from anything that I’M treating. Ophthalmology patients get better, and because vision is such an integral part of the human experience, both physically and emotionally, the gratification that one gets from returning someone to the sighted world is simply immeasurable. Oh yeah, we still have the coolest gadgets in all of medicine, and we get new ones to play with every year! And for whatever it’s worth, most of my best friends in medicine are also washed up blockhead ex-jocks, most of whom are slightly less brain-damaged than I.

Except, that is, my Orthopedic Surgery buddies…