Have Reimbursement Rules Taken the Joy Out of Being A Physician?

Photo Credit: The New York Times
Photo Credit: The New York Times

She came to the urgent care center with a sprained ankle. The primary care provider gave her excellent care, expertly applying evidence-based evaluation guidelines to her situation, and, thereby, avoiding unnecessary x-rays. By all measures, the provider’s care was excellent, but the interaction still ended up reducing his salary. You see, that patient’s only medical interaction that year was for this ankle sprain, and the provider was therefore held accountable for all of her primary care needs. Since she had not received a mammogram that year, or received a diabetes screening, he incurred an end-of-the-year penalty for failing to meet these quality standards.
Is it any wonder that many providers – primary care physicians, physician assistants, and even many beleaguered specialists – are increasingly dissatisfied with their jobs? What is happening to medical practice and what can we do to bring the joy back to being a healthcare provider?
I am early into a one-year quest to connect with leading thinkers from inside and outside medical care, so I can better understand why many clinicians are miserable in their careers, and much more importantly, what can be done to help them thrive at work even though an increasing number of outside parties are looking over their shoulder, assessing the quality of the care they provide .
These increasingly burdensome rules and regulations are making it hard to enjoy medical practice these days. Several decades ago, physicians largely practiced as autonomous professionals, governed by standards developed by their professional peers. Physicians underwent intense and prolonged training to develop the knowledge and skills to know how best to help patients with their problems. And the world generally stood back and accepted, on faith, that most physicians would provide excellent care to most of their patients. (To read the rest of this article, please visit Forbes.)

The Biggest Government Health Care Spender Since LBJ Was…Ronald Reagan?

reaganMany readers will recognize Ronald Reagan’s famous maxim that: “Government is not the solution to our problem; government is the problem.”  Some will even recognize his vehement opposition to Lyndon Johnson’s Medicare proposal, before the program was passed into law:

“We are faced with the most evil enemy mankind has known in his long climb from the swamp to the stars.  There can be no security anywhere in the free world if there is no fiscal and economic stability within the United States.”

Reagan even warned at one point:

“If this program passes, behind it will come other federal programs that will invade every area of freedom as we have known it in this country until we wake to find that we have socialism… You and I are going to spend our sunset years telling our children and our children’s children what it was like in America when men were free.”

Pretty overwrought words, and clearly an inaccurate prediction.  But that’s not what I want to write about now.  Instead I want to talk about happened when Ronald Reagan was president, when he passed what David Blumenthal and James Morone describe as “the largest Medicare expansion in decades.”  What was this expansion, and how did Reagan come to embrace it? …(Read more and view comments at Forbes)

Baby Thoughts from Andrew Solomon

far from the treeA quote from Far From the Tree I thought I’d share:

“There is no such thing as reproduction. When two people decide to have a baby, they engage in an act of production, and the widespread use of the word reproduction for this activity, with its implication that two people are but braiding themselves together, is at best a euphemism to comfort prospective parents before they get in over their heads”

I guess I should have read this book before my wife and I had our two kids!
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A Surprising Early Supporter of Obamacare: Eisenhower?

eisenhowerOn October 10, 1952, President Dwight Eisenhower gave a speech in Salt Lake City in which he reiterated his opposition to socialized medicine. In fact, he had long asserted that he would “use every single attribute and influence of the Presidential office to defeat any move toward socialized medicine.” But Ike also recognized that all Americans deserve some kind of basic medical care. Not long before his trip to Salt Lake, he had stated that: “Too many of our people live too far from adequate medical aid; too many of our people find the cost of adequate medical care too heavy.” Eisenhower’s compassion came in part from personal experience. He had seen his wife’s family “virtually wrecked” from having to pay big medical bills.
So how did Ike reconcile his opposition to socialized medicine with his recognition of medical needs? According to The Heart of Power, a wonderful book by David Blumenthal and James Morone, Eisenhower reconciled these two goals by pushing for federal subsidies of private insurance plans… (Read more and view comments at Forbes)

How Truman's Medicare Efforts Were Foiled by Red Baiting

trumanIn The Heart of Power, David Blumenthal and James Morone relate the 75 year history of presidential efforts (typically unsuccessful) to reform the U.S. healthcare system.  I used to think major reform efforts did not happen for many years after FDR’s New Deal.  After all, social security had taken a huge dent out of poverty among the elderly.  But healthcare costs were rising throughout the 1940s, and Harry Truman, FDR’s successor, was determined to provide all Americans with affordable healthcare.  In his 1948 State of the Union Address, Truman made his values clear.

“The greatest gap in our social security structure is the lack of adequate provision for the Nation’s health…this great Nation cannot afford to allow its citizens to suffer needlessly from the lack of proper medical care.”

But with the communist Soviet Union on the rise, Truman’s ideas were susceptible to accusations of socialism.  Republicans and conservative Democrats used the Health Committee on Expenditures in the Executive Department to look for communists that might be influencing Truman’s healthcare reform efforts… (Read more and view comments at Forbes)

Why It Is Crucial to Practice Your Sense of Humor Now!

the theory that would not dieIn The Theory That Would Not Die, Sharon Bertsch McGrayne brings to life many famous scientists and statisticians, the one of the moments that struck me most was when she described one of those people as he faced his death. That person was Jerome Cornfield, a prominent statistician at the NIH. Cornfield had been diagnosed with pancreatic cancer, and understood that he would be lucky if he lived more than six months. He had just undergone an operation to remove his cancer, a procedure known to be about as miserable to go through as any I’ve encountered, and one with a high operative mortality rate. A friend came into his hospital room and said: “Jerry, I’m so glad to see you.” Smiling, Cornfield replied, “That’s nothing compared to how happy I am to be able to see you.”
Near the end of his life, he passed on words of wonderful wisdom to his daughters: “You spend your whole life practicing your humor for the times when you really need it.”

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Who Said Statisticians Were Uninteresting?

ra fisherI recently read Sharon Bertsch McGrayne’s The Theory That Would Not Die, which recounts the controversial history of Bayes theorem in the world of statistics. To oversimplify quite a bit, Bayes theorem requires those using it to make an initial guess about, say, the probability that one outcome is more likely than another, and then the theorem helps them revise this probability estimate as new data comes in. Many statisticians hate this idea of starting with “a guess.” One such statistician is the very colorful, and very famous, R.A. Fisher, whom McGrayne described thusly in her book:

“Even with thick glasses he could barely see three feet and had to be rescued from oncoming buses. His clothes were so rumpled that his family thought he looked like a tramp; he smoked a pipe even while swimming; and if a conversation bored him, he sometimes removed his false teeth and cleaned them in public.”

All together now:  Eeeeewwwww!!!!

What's Fair About Price Discrimination in Pharmaceutical Markets

underground economistA while back, DVD companies hoping to sell their products in countries like Poland faced a dilemma.  They could sell their products at a nice profit in the booming U.S. market, but to sell products in those other countries, they had to lower their prices.  Such variable pricing is a common business practice.  All kinds of services are less expensive in Poland than in the United States.  An hour with a psychotherapist or personal trainer, for instance, is significantly cheaper in Warsaw than in New York City.  But small, non-perishable products like DVDs create big problems for manufacturers.  If the going price of such a product is significantly lower in Poland than the U.S., savvy business people will purchase large numbers of DVDs in Poland and ship them back to the United States to sell them for a hefty profit.  They can’t do the same with personal trainers or psychotherapists, to the chagrin, no doubt, of some people in those professions.

So DVD manufacturers came up with a clever idea.  As Tim Harford describes in his book The Undercover Economist: “The DVD industry agreed on a system of regional coding so that DVDs bought in the U.S. would not work in Europe,” and vice versa.
When some people found out about this arrangement, they were creeped out.  It seemed like the companies were up to their slimy old tricks.  How dare they doctor a DVD so that an honest consumer can’t play it on his or her DVD machine?  It felt like the DVD manufacturers were getting greedy.  If they were willing to sell DVDs at that price in Poland, after all, then clearly such lower prices must still be profitable.  Why wouldn’t they sell DVDs at that same price in the United States? …(Read  more and view comments at Forbes)

Great Quote on the Psychology of Science

riddle of the labyrinthI recently read Margalit Fox’s wonderful book, “The Riddle of the Labyrinth,” which tells the extraordinary tale of how three people, working in parallel, figured out the meaning of what, to me, look like random scribbles on ancient tablets – the language known as Linear B. In trying to deduce the riddle of these scribbles, one of the scholars highlighted in the book points out:

“A scholar’s worst enemy is his own mind. Facts are slippery things. Almost anything can be proved with them, if they are correctly selected. . . .”

Readers of my blog will know that I am very interested in the psychology of science. In this case, the person who ultimately solve the riddle of the language failed to solve the riddle for a long time as he was convinced the language could not be any form of Greek. Once he overcame his own preconception, he rapidly solved the rest of the riddle.
When trying to figure out how the world works, do your best not to let preconceptions stand in the way of an objective interpretation of the evidence.
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A Magician's Eye for Consumer Scams

dasani bottleOne of the themes running through Fooling Houdini that I like the most was the strong connection that Stone made between magic, con artistry, and even common business practices. Magicians have long been known for their ability to spot scams. After all, their profession is based on developing the ability to fool people. That is why Houdini, himself, spent much of the end of his career trying to debunk con artists. But as someone who teaches behavioral economics to business students, and in the process spends lots of time debating the ethics of exploiting consumer weakness, it was refreshing to see this passage from Stone’s book:

“Everywhere I looked, I saw rip-offs. Why do car rental agencies urge you to buy optional insurance when in most cases your own insurance, or credit card, covers any damage? Why does jock itch cream cost more than athlete’s foot medication, even though they’re the same thing? Is it because companies know they can charge a premium for a more embarrassing product? Why do Americans spend $8 billion each year on bottled water, when the two top-selling brands (Aquafina and Dasani) come from municipal sources? Why do so many investors buy mutual funds when most funds underperform the markets they’re supposed to one-up? (There are more funds than stocks. Think about that for a moment.)”
“Cruising down Interstate 15, I came upon a sign that read SPEED LIMIT 70 MPH ENFORCED BY AIRCRAFT and wondered if that, too, was a scam .”

Hard not to be a skeptic once you understand how easy it is to dupe people.