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.

Bob Ryan, the great Boston Globe sportswriter, is famous for a writing style in which he simply jots down short little “thoughlets”. He basically just throws out whatever’s on his mind, expanding on some thoughts, and just letting others dangle, tiny little flags sent up the flagpole. If you’ve ever read him, and if you pay attention, you notice that he occasionally revisits these “thoughtlets” with a much deeper examination.  This technique or style has been ripped off by countless other sportswriters, usually without attribution.

Over the course of my day-to-day life I find myself interested in countless little ideas, tiny thoughts, or random observations. Not all of them are worthy of the full attention of the “Restless Mind”, but I think a lot of them really  ARE interesting, and I really hate to lose  them. So I thought on occasion I, too, would steal this technique from Mr. Ryan, only I am going to openly acknowledge that it’s his, and openly thank him for giving me the idea. So, without further ado, here are some  random thoughts banging around between my ears…

1.)  Lacrosse.  I am absolutely up to my eyeballs in lacrosse this weekend, and loving every minute of it. My son Randy had a  game yesterday, and looking back I realized that I spent at least six hours in front of ESPNU watching NCAA lacrosse as well. It’s really a fantastic sport. I’m a little guy, and lacrosse would’ve been a great sport for me when I was younger. Unfortunately, I didn’t come upon lacroses until I was a high school junior, and I didn’t get a chance to actually play lacrosse until I was in college. I was a pretty typical football player turned lacrosse player — great wheels, no stick. I was a defensive midfielder before the position actually  existed. “Hey, Darrell, see that kid over there? Yeah, that one. The one who knows how to play lacrosse. Go beat the crap out of him and don’t let him score!” Yup, I was THAT guy.

When my oldest son, Danny, started playing in junior high school I rekindled my love for the game. I’ve been telling people for years that lacrosse is the perfect game for boys. You get to do everything your mother ever told you NOT to do: you get to run with a stick, and you get to HIT people with! Seriously, how good is THAT?! It’s funny, though, because it’s exactly this part of the sport that is putting this wonderful, lovely game at risk in our local public high school.

You see, our athletic director is concerned that lacrosse is inherently a dangerous sport. He’s concerned that the injury rate is, or will be, much higher than all other sports simply because it’s lacrosse. I don’t think that’s the case. As a matter of fact, after watching very high level lacrosse on television this weekend, I’m convinced it’s not the case. I say this after having watched my youngest son, Randy, get the snot beaten out of him in his last three games (Randy is an attackman who plays the “X.” position; he has the ball an awful lot making him an inviting target).

What the athletic director is actually seeing it is a rather unskilled version of the game. As such it’s really not any different from unskilled versions of any other contact sport. Who among us hasn’t seen an unskilled basketball team rough up the team made of five extremely skilled but rather slight hoopsters? Or the soccer team that consists of brutes, muscling their opponents off the ball? Or the classic example, the hockey team whose tactics consist largely of muggings on skates? No, it’s not the game. Lacrosse is no more or nor no less injury-prone than any other contact sport.

It’s really quite beautiful, and I have to make sure our athletic director realizes this.

2.)  Women’s lacrosse. If you love men’s lacrosse you’ve probably watched a game or two of women’s lacrosse. While I write this I’m watching the Virginia women beat Towson State in a playoff game. They have lacrosse sticks, they shoot at 6′ x 6′ goals, and the ball spends an awful lot of time in the air being passed from player to player. The similarities seem to end there, though. It’s a totally different game!

I’m I’m reminded of watching my sister play field hockey in high school. Man, talk about a game with lots and lots of rules, totally impenetrable to all but the chosen few who have been initiated in some secret athletic rite. I could never figure out why any whistle was blown in field hockey, and I have to confess that I’m just as bewildered watching women’s lacrosse. The women are very fast, clearly elite athletes, and they’re certainly holding lacrosse sticks and shooting at lacrosse goals.

I hope I figure out women’s lacrosse in less time than it took me to figure out field hockey!

3.) There was a  very insightful article, an interview of the great economist Gary Becker in the Wall Street Journal couple of weeks ago. Becker touched on all kinds of topics, and spent a little bit of time on one that’s very close to my world, namely healthcare economics. He’s a little frustrated, heck were ALL a little frustrated by the willful obfuscation foisted upon the great unwashed mass of humanity that doesn’t work inside the Washington DC beltway when it comes to health care economics.

A case in point is the effect of out-of-pocket expenses on the overall amount of money that is spent on healthcare in any given country. In the United States we presently spend about 17% of our GDP on healthcare. Out-of-pocket expenses make up only about 12% of total health-care spending. In Switzerland, however, a country widely acclaimed for a very effective health care system, and equally acclaimed for spending only 11% of GDP on healthcare, the Swiss have out-of-pocket expenses equal to about 31% of total spending.

Swiss consumers of medical care are assumed to  have the ability to make complex medical decisions on their own behalf. Do you think maybe, just MAYBE there is a correlation here? Do you think that perhaps the fact that Swiss patients individually own 31% of the skin in the game has anything to do with driving overall healthcare costs lower? That perhaps the fact that every healthcare transaction is roughly 1/3 the responsibility of a patient, thereby involving every single patient in the financial aspects of every single health care decision, might be in part responsible for a lower percentage of the GDP being spent on healthcare?

Nah. Couldn’t be that.

4.)  Aches and pains. My partner Greg Kaye turned 41 years old this week. Greg actually handled the “turning 41″ part much better than I did 50, only finding it difficult over the last month or so. Greg is also a former athlete, just a little less  “former” then yours truly. But Greg has struggled over the last month or so because of a couple of nagging injuries which have limited his athletic exploits, and consequently reminded him that he is no longer 21.

I’ve got pretty much the same chronic infirmities that I’ve had for several years. I’ve made my peace with them, at least I think I have. The difference for me now is that every time something new crops up I’m having a hard time putting aside the thought that it’s not just a little niggling effect of being 50 years old, but that it might actually be something serious. I’m starting to see friends, and friends of friends die. Some of them are dying from common things, and some of them are dying from relatively uncommon, weird things. I have a little bruise on my trachea right now. In all likelihood that’s all it is. The good news: I probably won’t put a tie on for a week or so. The bad news: until I put a tie back on I’m going to be wondering.

We used to call this “medical students disease”, the phenomenon where every medical student came down with whatever disease we happen to be studying at the time. I apparently was never cured of “medical students disease”!

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”…

Skyvision Centers has a subsidiary company called the Skyvision Business Lab. We do business process research for pharmaceutical companies, medical device companies, and other medical businesses in the eye care arena. One of the companies we have worked for is a very cool company that produces animated educational videos for a ophthalmologists and optometrists. I had an interesting experience while talking to their chief technology officer. It was interesting because the conversation proved our basic reason for existence at the Business Lab, that it is impossible for any company to develop, sell, and install any kind of product in our world without understanding the ins and outs of every day activities in an eye care practice.

Of course, I always find it extremely interesting when I’m right!

It was a tiny little point, really, but how could you know something this small and seemingly insignificant unless you had spent time on the “frontline” of medical practice? The chief technology officer for the video company was frustrated because doctors and their staff were not using this really cool product that they had purchased. Furthermore, because they weren’t using it, they were failing to buy downstream products from the video company. As it turns out the salespeople for this company were telling the doctors that this particular product should be “turned on” by the staff at the front desk of the office. This is exactly the wrong place because the front staff personnel simply have neither the time, nor the understanding, nor any incentive whatsoever to do this! The product actually works beautifully if it is “turned on” by the back-office staff. Bingo! Problem solved.

So what does this have to do with Electronic Medical Records (EMR), and for heaven’s sake what does this have to do with underpants? It’s simple, really. When was the last time you bought a totally new type of underpants, underpants that you had never seen before, and underpants that you had certainly never worn before, without trying them on? Furthermore, what’s the likelihood that you would allow someone else to design, fit, and choose a style  of underpants for you if that someone has not only never met you but has never even seen a picture of you?!  That’s the image I get every time I read an article about EMR.

In theory the concept of an electronic medical record that would allow permanent storage of every bit of medical information, with the ability to share that information between and among doctors and hospitals involved in the patient’s care is so logical and obvious that debating the point seems silly. If you have ever seen my handwriting, for example, you’d realize that the entire field of EMR was worth developing just to make doctors stop using pens and pencils! Trust me on this… the doctor hasn’t yet been trained who is also a specialist in penmanship.

I actually trained at  two of the pioneering hospitals in the use of electronic medical records, and indeed in the use of computers in medicine in general. Dr. Larry Weed and Dr. Dennis Plante at the University of Vermont were pioneers in the concept of using computing power to make more accurate medical diagnoses. Both the University of Vermont Medical Center and the Maine Medical Center were among the very first institutions to develop and implement digital medical records for the storage and use of clinical data like lab reports and radiology reports. In theory both of these areas make sense, but in practice the storage and display of clinical data is all that’s actually helpful in day-to-day practice.

If this is the case, if the acquisition, storage, and retrieval of critical data is helpful, the next logical step must be to do the same thing with the information obtained in doctor’s offices, right? Well, in theory this makes a ton of sense. The problem is that nearly none of the EMR systems now in place have been designed from the doctor — patient experience outward; they’ve all been designed from the outside in, kind of like someone imagining what kind of underpants you might need or might like to wear, and making a guess about what size would fit you. With a few exceptions, tiny companies that are likely to be steamrolled in the process, every single EMR on the market is the wrong fit for a doctor and a patient.

Why is this? How could this possibly be with all the lip service that is being paid to the doctor — patient relationship and the importance of getting better care to patients? It goes back to that same tiny little problem that the medical video company tripped over: it’s really hard to know how something should work unless you spend some time where the work is going to be done. Electronic medical records in today’s market are responsive to INSTITUTIONS, insurance companies and governments and large hospital systems. System before doctor, doctor before staff, staff before patient. Today’s EMR’s have been designed with two goals in mind: saving money and reducing medical errors. Should be a slamdunk at that, right? But even here the systems bat only .500, producing reams of data that will eventually allow distant institutions to pare medical spending, but neither capturing nor analyzing the correct data to improve both medical outcomes and medical safety. Fail here, too, but that’s another story entirely.

So what’s the solution? Well for me the answer is really pretty easy and pretty obvious. Send the underwear designer into the dressing room! Program design, programs of any type, are one part “knowledge of need” and one part plumbing. How can you know what type of plumbing is necessary unless you go and look at the exact place where the plumbing is needed? How can you know what size and what shape and what style of underwear will fit unless you actually go and look at the person who will be wearing the underwear? It’s so simple and so obvious that it sometimes makes me want to scream. Put the program designers in the offices of doctors who are actually seeing patients. Set them side-by-each. Make them sit next to the patients and experience what it’s like to receive care.

THEN design the program.

I’m available.The  Skyvision Business Lab is available. I have a hunch that the solution will hinge on something as simple and fundamental as my example above — front desk versus back office.  It doesn’t necessarily have to be me, and doesn’t necessarily have to be us, but it absolutely is necessary for it to be doctors and practices like Skyvision Centers, places where doctors and nurses and staff members actually take care of patients. Places where patients go to stay healthy or return to health. Places where it’s patient before staff, staff before doctor, doctor before system.

For whatever it’s worth I’m 5′8″ tall, I weigh 150 pounds, and I’m relatively lean for an old guy. I guess it’s a little embarrassing to admit this… I still wear “TightyWhiteys”, but I’m open-minded. I’m willing to change.

Just take a look at me first before you choose my underpants for me.

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.

Like most physicians my age I have been sued in a medical malpractice case. It happened to me many, many years ago, and the error in care actually happened before I did anything for that particular patient. An anesthesia accident occurred prior to the OR, and my role was to simply identify the problem, do what was necessary to stabilize the patient, and then refer the patient to the appropriate specialist. Although I had no role in the actions that caused the harm to my patient I was included in the lawsuit because my name was on the chart.

Welcome to the American medical malpractice experience.

While I have yet to be sued again (visualize me running through my house frantically tapping every wooden object), that first case brought an invitation to become an expert witness. As nervous as I was in the deposition for my own case I  managed not to drool, vomit, or soil myself ; this apparently constitutes the minimum requirement to be an expert witness in med-mal cases. I have been a consultant in dozens of cases in the years since. I enjoy the intellectual challenge of deconstructing  a case, the detective work involved in recreating the history. I find the tactical discussions with the attorneys to be intellectually stimulating, similar to creating a game plan in my former life as a football offensive coordinator. Each case unfailing provides some precious nugget, some valuable piece of information that can be brought back to my own practice to make our care and our outcomes better.

But mostly what I have learned from my exposure to the American medical malpractice tort system is that everybody loses every time the game is played.

Let’s break it down, shall we? I’ll use a case in which I was recently involved, among others, to illustrate (obviously all of the names and any other identifiers have been changed). Dr. Z saw Patient X who probably already had a particular disease in 2004. Dr. Z didn’t really pursue some of the findings present in the exam and history at that time, and in effect failed to make a timely diagnosis. Patient X then had a dramatic change in vision after a surgical procedure, a procedure that was done perfectly without any adverse events or complications. This dramatic decrease in vision was really a burden for Patient X, and so an attorney was hired and Dr. Z was sued for malpractice because he failed to make a particular diagnosis in 2004 which MAY have caused the loss of vision in 2006. As it turns out the loss of vision was NOT caused by the disease that went undiagnosed and Dr. Z prevailed at trial.

Let’s quickly look at another case, one in which I had no personal involvement but one that I am familiar with on a personal level. A young mother and father, parents of three healthy little kids, notice a bulge in the belly of their youngest. Maybe he’s two or three at the time. A little umbilical hernia, very common, a snap for a pediatric surgeon to fix, is the diagnosis. They live in a city with many very fine medical institutions and they choose one with a sterling reputation for the surgery. A terrible accident occurs during the surgery, a “never” event, a clear case of medical malpractice. Their beautiful third child suffers irreparable, irreversible brain damage and will now require 24/7/365 care for the rest of his life, a life that will likely be cut short, but a life that will dramatically alter the lives of this young couple and their two other children. The case never goes to trial; the hospital and all of the doctors settle the case and the devastated couple and their children receive a very large settlement.

Let’s look at these cases, shall we? Let’s see who won and who lost. First off we should deal with the lawyers. Think of the defense lawyers, the people who defend the doctors (and their malpractice insurance companies), as the “house”. Defense lawyers ALWAYS get paid, just like the casino always takes its cut. Neither a winner nor a loser, the defense attorney just takes his cut. How about the plaintiff’s attorney? Didn’t they lose the first case and win the second? Well, sort of. A better way to think about the lawyers who sue doctors is to consider them professional gamblers who place their bets with someone else’s money. Some are backed by investors who cover their expenses, and others simply use the proceeds of the first settlement they receive. If the defense attorneys are the “house”, the plaintiff’s attorneys are professional gamblers who make their bets using “house money”. Neither winners nor losers here, just scavengers who feed on the carcasses of…

…EVERYONE ELSE! The doctors, the patients, their families, the hospitals, even the spectators–you and me. Everyone loses. You don’t agree? Let’s dial in a closer look.

In the first example Dr. Z made a mistake. He made a delayed diagnosis. Didn’t provide very good care for that particular problem. When Patient X had something bad happen he was convinced it was because Dr. Z missed a diagnosis, and an enterprising plaintiff’s attorney convinced Patient X that he suffered his bad vision because of malpractice. So they sued. It’s pretty clear that the patient, poor X, lost any which way you look at this. Bad vision in one eye. Hopes raised that not only would that bad ol’ Dr. Z be made to pay for his mistake, but Patient X would also receive a financial settlement, maybe even a windfall. BZZZT. Wrong. Sorry. Johnny, tell Patient X about our lovely parting gifts. Not only do you STILL have bad vision, but now you’ve had all of your false hopes dashed adding bitter disappointment to your loss column, not to mention all of the time you spent in the company of all kinds of lawyers.

But…but…what about Dr. Z? He WON. Really? Ya think? Look back at the story. Dr. Z was sued in 2006. He has had to live with this case and everything that went along with it for 4 years. Time out of the office. Time on the phone with lawyers. Giving depositions. Reading depositions in which his patient and a hired-gun physician expert said he was a bad doctor. 4 years of wondering and worrying, thinking about the case, thinking about losing. Looking at every patient as “the next case”. No, Dr. Z lost, too. My world is littered with the carcasses of physicians, and lives, and practices, and marriages, and families that were destroyed by the process of malpractice cases that the doctors WON. Alcohol abuse, depression, suicide, all in cases that the doc won. Nah…Dr. Z lost, too.

How about the second case? Pretty clear that the doctors and the hospital lost this one. Big time. Huge settlement. They messed up and paid the price. That young family won. Made ‘em pay, just like the fancy lawyer ads on TV. Big money. But really? Seriously? That child was still grievously injured, and that family is still living with the knowledge that he will never be the child he might have been. 24/7/365 care for 10 years. Housing, schedules, LIVES all determined all the time by medical malpractice, a case in which they prevailed legally. Winners? Hardly. I know this family, and they are gracious and wonderful people who have soldiered on for 10+ years, the only ease being a freedom from the financial burden of their tragedy. What if they had gone to trial and lost? That happens, you know. Sometimes real malpractice happens but the doctors win in court. Nope, no patients ever win in medical malpractice. Not here; not ever.

And the spectators? You and me? Well, we lose every single day. Every time a doc does a little extra just to cover himself in case of a trial, orders an extra test or X-Ray that doesn’t really do anything to promote a better outcome but makes for a little better paper trail, we all suffer due the expense of that defensive medicine. Every time we wonder about why our doctor might be ordering that test or asking that question we lose. When a doctor looks at a patient and sees a potential lawsuit instead of a patient who needs help he loses. The patient loses. We all lose. Think about how many medical errors there are that happen again and again because they are never reported, and therefore are never evaluated and examined to see if they could be prevented, because a doctor or a hospital was afraid that reporting the error would launch a lawsuit. Lose.  Everybody loses in the Medical Malpractice Game.

Well, ALMOST everybody. I guess the “house” continues to win, and the folks gambling with the “house’s money” continue to win. It’s just everybody else who loses. Everybody who counts like every single patient and every single doctor in every single medical malpractice case.

Everybody…like you and me.

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…

Customers? Whadda we need customers for? We don’t need no stinkin’ customers. We got PATIENTS!

Has anybody else noticed the forgotten players in the great American Healthcare debate? You know, the people on the receiving end of the health care? The patients? The only time we see any real attention being paid to a patient, the person in a doctor’s office or a hospital, is when someone in Congress or the White House is trying to come up with the title of a Bill or proposal. “The Patient Protection and Affordable Care Act” is the latest flag to be hoisted above an omnibus that otherwise pretty much ignores everything about the patient, about what it means to be a patient and how it feels to be a patient and what matters to a patient receiving medical care.

I’ve written elsewhere on “Random Thoughts” that medicine is the ultimate consumer-service business. The more you think about that the more obvious it becomes, I think. When a patient seeks medical care there is something that we either need or want, sometimes very badly and sometimes very urgently. We are seeking a service, and like any service industry the patient is the customer in that particular relationship. Very few of us, even doctors, are able to be truly informed customers when we are in the doctor’s office or the hospital; there’s just too much to know about too much, even if we have the time to do lots of research, and even if we are not spending any time researching costs. This is such an unbalanced service provider/customer relationship that innumerable ethical guidelines, regulations, and laws have evolved to mitigate against the provider abusing this knowledge mismatch.

What is it that we read about when patients complain about their experiences while obtaining medical care? Do they complain about outcomes, how they eventually turned out after receiving medical care? Not really, in part because people who get medical care almost always get better in America.  What we hear about, time and again, is what their EXPERIENCE was like. How they FELT about the experience, and what was either good or bad about the experience. And let’s face it, people are much more apt to complain about something they didn’t like than they are to praise something they did. When I look at the proposals to “reform” American healthcare  I don’t see anything that even touches on this in passing, and I see all kinds of stuff that is almost guaranteed to make the experience worse.

All because no one has either the insight or the ball’s to look at this whole issue through the eyes of the most important player in the game, the patient. The customer. It’s all about the process and the price, all evaluated from the provider side of the service relationship with no thought given to the customer.

So what exactly am I talking about? What are some examples, Smart Guy? Well–glad you asked; I just happen to have a couple handy. The “flavor of the moment” in the reform movement is the very large healthcare organization that encompasses both physicians and hospitals, organizations that negotiate with payers as a unified whole, and organizations that specifically pay their doctors a salary (presumably NOT tied to the volume of work done by an individual doctor). There are a number of them in the U.S., and most of them are cut from the same cloth. Let’s call this organization the “World Class Hospital”.

It’s 4:59 PM on a Tuesday and you call your doctor’s office; it’s not yet 5:00 so her secretary picks up the phone. She can see you in 5 weeks. You have an emergency? Why yes, she IS in the office right now, and yes she will be here for another hour,  but she doesn’t have an open appointment even though she’s been your doctor for X years. Go to the Emergency Room if you have an emergency. Make the same call at 9:01 in the morning and you might find an open slot, or you might get an associate, or maybe not. Make the call at 5:01 PM and you never even get your doc’s office. Heck, you sit on hold–press 4 to talk to a nurse.  Do not pass go, do give us $200 on top of any exam fee, and proceed directly to the ER.

So you are directed to the ER, because that’s how it happens in “World Class Hospital”, and you now cool your heels for 3 or 4 hours while waiting to receive care from 3 or 4 doctors whom you’ve never met. But don’t worry, they have your Electric Medical Record so it’s all good. They don’t know YOU, of course, but now they know your CHART, and you and your chart are taken care of by Dr. Stranger and his team. After 3 or 4 hours of waiting they  took another hour to take care of something that your own doc would have covered in 10 minutes, but hey, you’re in “World Class Hospital” and you just received a best-in-class medical outcome. What’s your beef?

Two days later you receive the bill for your successful medical outcome. Amazing how efficient “World Class Hospital” is when it comes to getting that bill out, huh? Your bill is 3 pages long, with all kinds of technical jargon and fancy financial lingo, and My God it looks like you were in ICU for a week. Who are all these doctors who I supposedly met? What are all of these extra charges, these “facility fees”? I just had a little problem that I wanted my doctor to take care of. I have Medicare; it’s supposed to be simple. Isn’t that what all of these new plans are supposed to copy, Medicare? It’s now 30 days later; who are all of these people calling me to ask how and when I’m going to pay this bill that I can’t understand? They sure have a lot of people to call me, what with how hard it was to talk to someone when I was sick.

It’s all about process. It’s all about the system. System and hospital and money before doctor, doctor before staff, and staff before patient. Think about that. You, the patient, are the customer, and you are last in line. Would you stand for this anywhere else in your life? We’ve proven at Skyvision Centers that it’s possible to put the patient first, before the doctor or the staff or the insurance company. You can buy Almay cosmetics at Nordstroms, Dillards, or Kmart. Same price. Just like cataract surgery, it costs the same no matter where you go, and the outcomes are almost identical just like Almay is Almay no matter where you buy it. But you sure feel better buying it at Nordstroms, don’t you? They put YOU, the CUSTOMER first in line. YOU are the most important player in the game.

Healthcare reform, at least what’s in front of Congress now, and the proposals to make more and more of your experience like “World Class Hospital”? Meh…not so much. You’re a patient, after all. Can’t you just hear the discussions behind closed doors, in Congress, in the White House, in the back rooms at United Healthcare et. al. and in the executive offices at “World Class Hospital”: Customers? Whadda ya talkin’ about, customers. We don’t need no stinkin’ CUSOTMERS. Ya gotta CARE about customers. We got it way better…we got PATIENTS!

Nobody cares about patients.